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

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

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

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

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

• When you may change your enrollment
• How you can cover your family members
• What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire
• 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 your carrier directly for address updates and questions about your benefit coverage.

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

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

Contact your employing or retirement office if you want to change from Self Only to Self Plus One or Self and Family. If you have a Self and Family enrollment, you may contact us to add a family member.

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits. Please tell us immediately of changes in family member status, including your marriage, divorce, annulment, or when your child reaches age 26. We will send written notice to you 60 days before we proactively disenroll your child on midnight of their 26^th birthday unless your child is eligible for continued coverage because they are incapable of self-support due to a physical or mental disability that began before age 26.

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

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

Family members covered under your Self and Family enrollment are your spouse (including your spouse by valid common-law marriage if you reside in 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.

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

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

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

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

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

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2024 benefits of your prior plan or option. If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option.  However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2023 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

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

When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service. If you do not meet this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of Coverage (TCC).

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

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

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

You may be eligible for spouse equity coverage or assistance with enrolling in a conversion policy (a non-FEHB individual policy).

If you are an enrollee, and your divorce or annulment is final, your ex-spouse cannot remain covered as a family member under your Self Plus One or Self and Family enrollment. You must contact us to let us know the date of the divorce or annulment and have us remove your ex-spouse. We may ask for a copy of the divorce decree as proof. In order to change enrollment type, you must contact your employing or retirement office. A change will not automatically be made.

If you were married to an enrollee and your divorce or annulment is final, you may not remain covered as a family member under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage to you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get information about your coverage choices. You can also visit OPM's website at https://www.opm.gov/healthcare-insurance/life-events/memy-family/im-separated-or-im-getting-divorced/#url=Health. We may request that you verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment.

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

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

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

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

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

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

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

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed, and your coverage will not be limited due to pre-existing conditions.  When you contact us, we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act's Health Insurance Marketplace in your state.  For assistance in finding coverage, please contact us at 888-882-8633 or visit our website at www.avmed.org.

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

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

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 800-882-8633 or write to us at 3470 NW 82nd Avenue, Doral, FL 33122. You may also request replacement cards through our website: www.avmed.org.

You get care from “Plan providers” and “Plan facilities.” You will only pay your applicable cost-sharing (copayments, deductibles, and/or coinsurance) if you use our Open Access option.  If you use your Open Access program you can receive covered services without a required referral from your primary care provider or by another provider in the network.

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

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

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

We list Plan providers in the provider directory, which we update periodically.  The list is also on our website.

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

This plan provides Care Coordinators for complex conditions and can be reached by calling 800-972-8633 (option #3) or by email at: CM@avmed.org for assistance.

Plan facilities are hospitals and other facilities in our service area that we contract with to provide covered services to our members.  We list these in the provider directory, which we update periodically.  The list is also on our website. 

It depends on the type of care you need. First, you and each family member must choose a primary care provider. This decision is important since your primary care provider provides or arranges for most of your health care.

Your primary care provider can be a family practitioner, internist or pediatrician. Your primary care provider will provide most of your healthcare.

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

If you are seeing a specialist when you enroll in our Plan, and your current specialist does not participate with us, you must receive treatment from a specialist who does.

Generally, we will not pay for you to see a specialist who does not participate with this Plan.

• If are seeing a specialist and you specialist leaves the Plan, call us, we will help you select a new one. 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
  • reduce our service area and you enroll in another FEHB plan

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

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

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

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 800-882-8633. If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

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

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

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

Since your primary care provider arranges for inpatient hospitalizations, the pre-service claim approval process only applies to care shown under Other services.

You must get prior approval for certain services.  You should remember that services provided or received without prior Plan authorization from AvMed when authorization is required, or services beyond the scope of practice authorized for a Health Professional under applicable state law, are not covered unless such services have otherwise been expressly authorized under the terms of this Contract or when required to treat an Emergency Medical Condition.  Furthermore, if an inpatient admission is extended beyond the number of days initially approved, without prior Plan authorization for the continued stay, it may result in services not being covered.  Before a service is performed, you should verify with your Health Professional that the service has received prior Plan authorization.  If you are unable to secure verification from your Health Professional, you may also call 800-882-8633.

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

For certain services, 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.

We call this review and approval process preauthorization. Your physician must obtain authorization for the following services such as, but not limited to:

• Hospitalization
• Certain medications (including Sexual Dysfunction medication)
• Gender affirming surgery. Certain criteria applies. See Standard Option page 41 or HDHP Option page 87: Section 5(b), "Reconstructive surgery"
• Growth hormone therapy (GHT)
• Most laboratory testing; and
• Other comprehensive diagnostic and treatment services

First, your physician, your hospital, you, or your representative, must call us at 800-882-8633 before admission or services requiring prior authorization are rendered.

Next, provide the following information:

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

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

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

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

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

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

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM.  Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 800-882-8633.  You may also call OPM’s FEHB 3 at 202-606-0737 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review.  We will cooperate with OPM so they can quickly review your claim on appeal.  In addition, if you did not indicate that your claim was a claim for urgent care, call us at 800-882-8633.  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.

Obstetrical care benefits are covered and include hospital care, anesthesia, diagnostic imaging and laboratory services for conditions related to pregnancy. 

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

The requesting obstetrical provider should obtain authorization by faxing a preauthorization request form to 800-552-8633.

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

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

If prior approval is not given for services provided by a non-network facility/provider, the Health plan shall have no liability or obligation whatsoever, on account of services or benefits sought or received by any member from any non-network physician, health professional, hospital or other health care facility, or other person, institution or organization.

If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below. If your claim is in reference to a contraceptive, call 800-882-8633.

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

3. Write to you and maintain our denial.

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

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

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

Example: When you see your primary care provider, you pay a copayment of $25 per office visit, and when you go in the hospital, you pay $300 per day for the first three days per admission.

A deductible is a fixed expense you must incur for certain covered services and supplies before we start paying benefits for them.

The calendar year deductible is $500 per person under the Standard Option and $1,600 under the HDHP Option. Under a Self Only enrollment, the deductible is considered satisfied and benefits are payable for you when your covered expenses applied to the calendar year deductible for your enrollment reach $500 under the Standard Option, or $1,600 under the HDHP Option.  Under a Self Plus One enrollment, the deductible is considered satisfied and benefits are payable for you and one other eligible family member when the combined covered expenses applied to the calendar year deductible for your enrollment reach $1,000 under Standard Option, or $3,200 under the HDHP Option. Under a Self and Family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $1,000 under the Standard Option, or $3,200 under the HDHP Option.

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

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

Example: In our Plan, you pay 20% of our allowance for durable medical equipment

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

After your out-of-pocket expenses, including any applicable deductibles, copayments and coinsurance total $4,500 for Self Only, or $9,000 for Self Plus One and Self and Family enrollment under the Standard Option plan, or total $4,000 for Self Only, or $6,750 for Self Plus One and Self and Family enrollment under the HDHP Option in any calendar year, you do not have to pay any more for covered services.

Example Scenario: Your plan has a $4,500 Self Only maximum out-of-pocket limit and a $9,000 Self Plus One or Self and Family maximum out-of-pocket limit. For Self Only, if you have out-of-pocket qualified medical expenses of $4,500, any remaining qualified medical expenses for that individual will be covered fully by your health plan. With a Self Plus One enrollment, the out-of-pocket maximum is $9,000, both individuals would have a $4,500 out-of-pocket limit each, and any remaining qualified medical expenses for those individuals will be covered fully by your health plan.

With a Self and Family enrollment, the out-of-pocket maximum is $9,000, one individual would have a $4,500 out-of-pocket limit, and a second family member, or an aggregate of other eligible family members will continue to accrue out-of-pocket qualified medical expenses up to a maximum of $9,000 for the calendar year before their qualified medical expenses will begin to be covered in full.

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

• Specialty drugs, out-of-pocket maximum of $2,500 per member per calendar year (applies to Standard Option only)
• Prescription drug brand additional charges
• Services this plan doesn't cover
• Expenses for services and supplies that exceed the stated maximum dollar or day limit
• Expenses from utilizing out-of-network providers

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

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

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

Facilities of the Department of 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” for out-of-network emergency services; out-of-network non-emergency services provided with respect to a visit to an in-network health care facility; and out-of-network air ambulance services.

A surprise bill is an unexpected bill you receive for:

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

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

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

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to  www.avmed.org or contact the health plan at 800-882-8633.

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

Professional services of physicians

• In physician’s office
• Second surgical opinion

Note: If the member chooses a non-Plan Physician for the second surgical opinion, the member will be responsible for 40% of the amount of reasonable and customary charges.

$25 per visit to your primary care provider

$45 per visit to a participating specialist

Professional services of physicians

• In an urgent care center
• During a hospital stay
• In a skilled nursing facility
• Office medical consultation
• Advance care planning
• At home

Nothing

Note: AvMed's Telehealth Services provide anytime remote access to board-certified doctors from your home, your office, or on the go.  Just 15 minutes after a simple sign-up, members can speak with a doctor about non-emergency medical issues by phone or by secure video using a computer, tablet, or smartphone.  

Nothing

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine pap test
• Pathology

$25 per visit to your primary care provider

$45 per visit to a participating specialist

• X-ray
• Ultrasound
• Electrocardiogram and EEG
• CT/CAT Scans
• PET Scans
• MRI

Note: Prior authorization is required.

20% of the contracted rate (calendar year deductible applies)

Routine physical annually

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

• Immunizations such as Pneumococcal, influenza, shingles, tetanus/Tdap, and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at
  https://www.cdc.gov/vaccines/schedules/
• Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening.  For a complete list of screenings, go to the
  U.S. Preventive Service Task Force (USPTF) website at
  https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations.
• Individual counseling on prevention and reducing health risks
• Preventive care benefits for women such as Pap smears, gonorrhea, prophylactic medications to protect newborns, annual counseling for sexually transmitting infections, contraceptive methods, and screening for interpersonal and domestic violence.  For a complete list of preventive care benefits for women go to the Health and Human Services (HHS) website at
  https://www.healthcare.gov/preventive-care-women/
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder

Nothing

• Routine Prostate Specific Antigen (PSA) test – one annually for men age 40 and older
• Mammograms (Routine and non-routine)
• Adult Immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule. 
• Medical Nutrition Therapy and Intensive Behavioral Therapy for the prevention of obesity related comorbidities as recommended under the U.S. Preventive Services Task Force (USPSTF A and B recommendations.

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

Nothing

Not covered:

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

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

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

Nothing

Not covered:

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

All charges

Complete maternity (obstetrical) care, such as:

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

Nothing

• Delivery

• Breastfeeding support, supplies and counseling for each birth

Nothing

Note: Here are some things to keep in mind:

• You do not need to precertify your vaginal delivery; see pages 19 and 20, Section 3. How You Get Care, "How to request precertification for an admission or get prior authorization for Other services" for other circumstances, such as extended stays for you or your baby.
• You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary.
• We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).

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

Contraceptive counseling on an annual basis

A range of voluntary family planning services, limited to:

• Voluntary sterilization (e.g. tubal ligation, vasectomy) See surgical procedures Section 5 (b)
• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo Provera)
• Intrauterine devices (IUDs)
• Diaphragms
• Genetic testing

Note: All genetic testing requests will be reviewed for medical necessity.

Note: We cover oral contraceptives under the prescription drug benefit

Nothing

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic counseling

Diagnosis and treatment of infertility such as:

• Artificial insemination:
  • Intravaginal insemination (IVI)
  • Intracervical insemination (ICI)
  • Intrauterine insemination (IUI)
• Medically necessary hormone testing
• Semen analysis
• Sperm function testing
• Chromosomal analysis
• Medical imaging
• Surgical correction of genitourinary tract abnormalities
• Fertility preservation for Iatrogenic Infertility

$25 per visit to your primary care provider

$45 per visit to a participating specialist

• Fertility drugs

See Section 5(f)

Note: Infertility is defined as the inability of an individual to achieve conception after one year for individuals under age 35 and six months for individuals age 35 and older; or the inability of an individual to achieve conception after egg-sperm contact through the use of artificial insemination. Infertility may also be established through an evaluation based on medical history and diagnostic testing.

Not covered:

• Assisted reproductive technology (ART) procedures, such as:
  - In vitro fertilization (IVF)
  - Embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer(ZIFT)

• Services and supplies related to ART procedures
• Surgery for the enhancement of fertility
• Cost of donor sperm
• Cost of donor egg

• Testing and treatment

$50 per course of testing

• Allergy injections

$25 per office visit

• Allergy serum

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 under Organ/Tissue Transplants on page 44.

• Respiratory and inhalation therapy
• Cardiac rehabilitation following qualifying event/condition is provided for up to 18 sessions
• 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.

Note: We only cover GHT when we preauthorize the treatment. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment.  We will only cover GHT services and related services and supplies that we determine are medically necessary.  See Other services under You need prior Plan approval for certain services on page 19.  Please refer to your provider directory for a list of authorized providers for this treatment or contact us at 888-882-8633. 

$25 per visit to your primary care provider

$45 per visit to a participating specialist

Short-term therapy for acute condition for which therapy applied for a consecutive two calendar month period (per condition) can be expected to result in significant improvements for 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 medically necessity for skilled services; and
• indicates the length of time the services are needed.

$45 per visit to a participating specialist

Not covered:

• Long-term rehabilitative therapy
• Exercise programs

Short-term speech therapy, when medically necessary, for acute conditions for which therapy applied for a consecutive two calendar month period (per condition) can be expected to result in significant improvement.

$25 per visit to your primary care provider

$45 per visit to a participating specialist

Coverage for Habilitative Services is covered the same as physical, occupational and speech therapy and includes services for Applied Behavior Analysis.

$25 per visit to primary care provider

$45 per visit for physical, occupational and speech therapies

• 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 Section 5(a) Preventive care, children.

Nothing

• External hearing aids (limited to $3,000 per year) and testing to fit them 
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants

Note: For benefits for the devices, see Section 5(a) Orthopedic and prosthetic devices.

Not covered:

• Hearing services that are not shown as covered

• Annual eye refractions to determine the need for vision correction for children through age 17
• Diagnosis and treatment of diseases of the eye

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

$25 per visit to your primary care provider

$45 per visit to a participating specialist

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

$45 per pair 

Not covered:

• All other vision testing (eye examinations and refractions)
• Eyeglasses or contact lenses (including replacement of lenses provided during the same calendar year)
• Eye exercises and orthoptics
• Radial keratotomy and other refractive surgery

$25 per visit to your primary care provider

$45 per visit to a participating specialist

Not covered:

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

• Artificial limbs and eyes
• Prosthetic sleeve or sock
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
• External hearing aids and testing to fit them (External hearing aids limited to $3,000 per year)
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants
• Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy.

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

20% of the contracted rate (calendar year deductible applies)

Not covered:

• Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups
• Non orthopedic brace
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Penile implants 
• Prosthetic replacements provided less than 3 years after the last one we covered

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

• Oxygen
• Dialysis equipment
• Hospital beds
• Standard wheelchairs
• Crutches
• Insulin pumps
• Ostomy and catheter supplies

Note:   Coverage for orthotic appliances is limited to leg, arm, back, and neck custom-made braces when related to a surgical procedure or when used in an attempt to avoid surgery and are necessary to carry out normal activities of daily living, excluding sports activities.  Coverage is limited to the first such item; repair and replacement is not covered.

Note:   Call us at 800-882-8633 as soon as your Plan physician  prescribes this equipment.  We will arrange with a healthcare provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

Not covered:

• Medical supplies such as corsets which do not require a prescription
• Audible prescription reading devices
• Speech generating devices
• Motorized wheelchairs
• Non-standard wheelchairs
• All other orthotic appliances

All charges

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

20% of the contracted rate (calendar year deductible applies)

Not covered:

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

• Manipulation of the spine and extremities

Adjunctive procedures such as ultrasound, electrical muscle stimulation, vibratory therapy, and cold pack application

$25 per visit to your primary care provider

$45 per visit to a participating specialist

No benefit

Coverage is provided for:

• Tobacco Cessation programs, including individual/group/telephone counseling, and for over-the-counter (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.

• Diabetes self-management

$25 per visit to your primary care provider

$45 per visit to a participating specialist

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

A comprehensive range of services, such as:

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

Note: Morbid Obesity is a condition in which an individual weighs 100 pounds or 100% over his or her normal weight according to current underwriting standards; eligible members must be age 18 or over. 1. Weight loss surgery may be an option for a select group of patients with clinically severe obesity or morbid obesity. When non-evasive methods of weight reduction have been exhausted, surgery will be considered for individuals with a Body Mass Index (BMI) of greater than or equal to 40 or a BMI of 35 or greater, with coexisting conditions. Individuals may qualify for surgery if they have been morbidly obese for a period of five (5) years or more. 

Morbid obesity is defined as having a BMI in excess of 40 or a BMI in excess of 35 with any of the following severe co-morbidities: coronary heart disease, diabetes mellitus, clinically significant obstructive sleep apnea, and medically refractory hypertension; 2. Member has completed growth (18 years of age or documentation of bone growth completion); 3. Recent psychiatric/psychological evaluation to rule out eating disorder(s) or psychological disturbance, such as Binge Eating Disorder, active drug abuse, active suicidal ideations/thoughts, borderline personality disorder, schizophrenia, terminal illness or uncontrolled depression, which may impede post-operative recovery and dietary restrictions; 4. Documentation (e.g., type, duration, amount of weight loss) of all prior weight control/loss programs including: food supplements, appetite suppressants, dietary regimens/treatments, and exercise programs; 5. Documentation of non-operative, physician supervised integrated weight reduction program consisting of dietary therapy, appropriate exercise, behavior modification and psychological support: Four (4) physician visits are required over a six (6) month period to document supervision; the program must maintain at least a six (6) month duration, within three (3) years of request for surgical intervention.

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

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

$25 per visit billed by your primary care provider

$45 per visit billed by a participating specialist

Treatment of burns

$100 Copayment

Voluntary sterilization (e.g., tubal ligation, Vasectomy)

Nothing

Not covered:

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

All charges

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

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

• Gender Affirming surgery including, but not limited to, mastectomy, gonadectomy (hysterectomy and oophorectomy in female-to-male and orchiectomy in male-to-female), and genital reconstruction (in female-to-male: vaginectomy, urethroplasty, metoidioplasty, phalloplasty, scrotoplasty, and placement of a testicular and erectile prosthesis; in male-to-female: penectomy, vaginoplasty, labiaplasty, and clitoroplasty).
• Feminizing procedures including, but not limited to, Rhinoplasty, face-lifting, lip enhancement, facial bone reduction, blepharoplasty, breast augmentation, liposuction of the waist (body contouring), reduction of hyoid (chondroplasty), hair removal, voice modification surgery (laryngoplasty or shortening of the vocal cords), and skin resurfacing.
• Masculinizing procedures including, but not limited to, chin implants, nose implants, and lip reduction. In addition, Abdominoplasty, brow lift, calf implants, cheek/malar implants, chin/nose implants, collagen injections, liposuction, mastopexy, and pectoral implants.
  

Note: Gender affirming surgery may be covered when ALL of the following criteria are met:

$25 per visit billed by your primary care provider

$45 per visit billed by a participating specialist

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.
• Procurement, cryopreservation or storage of embryo, sperm, oocytes for the preservation of fertility and the cryopreservation, storage, and thawing of reproductive tissue (i.e., ovaries, testicular tissue).

All charges

Oral surgical procedures, limited to:

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

$25 per visit billed by your primary care provider

$45 per visit billed by a participating specialist

Not covered:

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

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. See Other services under You need prior Plan approval for certain services on page 19. The medical necessity limitation is considered satisfied for other tissue transplants if the patient meets the staging description and can safely tolerate the procedure.  
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 

$25 per visit billed by your primary care provider

$45 per visit billed by a participating specialist

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

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

$25 per visit billed by your primary care provider

$45 per visit billed by a participating specialist

Hematopoietic stem cell or bone marrow transplants

The Plan extends coverage for the diagnoses as indicated below.

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

Note: Treatment must be approved by the Plan’s medical director in accordance with the Plan’s protocols. AvMed will request the medical evidence we need to make our coverage determination.

$25 per visit billed by your primary care provider

$45 per visit billed by a participating specialist

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

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

• Allogeneic transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • 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
  • Hemoglobinopathy
  • Marrow failure and related disorders (i.e., Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
  • Multiple Myeloma
  • Multiple Sclerosis
  • Myleoproliferative Disorders
  • Myelodysplasia/Myelodysplastic syndromes
  • Non-small cell lung cancer
  • Ovarian cancer
  • Paroxysmal Nocturnal Hemoglobinuria
  • Prostate cancer
  • Renal cell carcinoma
  • Sarcomas
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
  • Sickle cell disease 

• Autologous transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic myelogenous leukemia
  • Chronic lymphocytic lymphoma/ small lymphocytic lymphoma (CLL/SLL)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphom
  • Neuroblastoma
  • Small cell lung cancer                                                                   

• Autologous transplants for the following autoimmune diseases:
  • Multiple sclerosis
  • Scleroderma
  • Scleroderma-SSc(severe, progessive)
  • Systemic lupus erythematosus
  • Systemic sclerosis

$25 per visit billed by your primary care provider

$45 per visit billed by a participating specialist

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

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

Hematopoietic stem cell or bone marrow transplants

The Plan extends coverage for the diagnoses as indicated below.

• Allogeneic transplants for: 
  • Beta Thalassemia Major 
  • Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Sickle cell anemia
• Autologous transplants for:
  • Advanced childhood kidney cancers
  • Advanced Ewing sarcoma
  • Aggressive non-Hodgkin’s lymphomas (Mantle Cell lymphoma, adult T-cell leukemia/lymphoma, peripheral T-cell lymphomas and aggressive Dendritic Cell neoplasms)
  • Breast Cancer
  • Childhood rhabdomyosarcoma
  • Epithelial Ovarian Cancer
  • Mantle Cell (Non-Hodgkin lymphoma)

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.

$25 per visit billed by your primary care provider

$45 per visit billed by a participating specialist

Not covered:

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

Professional services provided in –

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

Nothing

Room and board, such as

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

$300 a day for the first three days per admission

(calendar year deductible applies) 

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and X-rays
• Administration of blood and blood products
• Blood or blood plasma, only if not donated or replaced
• Dressings, splints, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services
• Take-home items
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home (Note: calendar year deductible applies.)

Nothing

Not covered:

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

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

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.  If you have outpatient surgery and it turns into Observation care that exceeds 24 hours, only outpatient surgery copay will apply.

$300 copay per visit

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

All charges

• 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

We provide supportive and palliative care for a terminally ill member in the home or hospice facility.  Services include:

• Inpatient and outpatient care;
• Family counseling

Note: These services are provided under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness, with a life expectancy of approximately six months or less.

Local professional ambulance  service, including air ambulance, when medically appropriate and ordered or authorized by a Plan doctor.

Nothing

• Emergency care at a participating doctor’s office

$25 per visit to your primary care provider

$45 per visit to your participating specialist

• Emergency care at a participating urgent care center

$40 per visit

• Emergency care at a non-participating urgent care center

$60 per visit

• Emergency care at a hospital emergency room

Note: We waive the ER copay if you are admitted to the hospital.  If you go through the Emergency Room and need to stay for Observation care which exceeds 24 hours, only the ER copay will apply.

• Emergency care at a doctor’s office
• Emergency care at an urgent care center

$60 per visit

• Emergency care at a hospital emergency room

Note: We waive the ER copay if you are admitted to the hospital.  If you go through the Emergency Room and need to stay for Observation care which exceeds 24 hours, only the ER copay will apply.

Not covered:

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

• Professional ambulance service when medically appropriate.
• Air ambulance, when medically necessary and preauthorized by Medical Director or Chief Medical Officer.

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

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

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

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

• Diagnostic evaluation
• Crisis intervention and stabilization for acute episodes
• Medication evaluation and management  (pharmacotherapy)
• Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
• Treatment and counseling (including individual or group therapy visits)
• Diagnosis and treatment of 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
• Applied Behavioral Analysis services

$25 per visit to your primary care provider

$45 per visit to a participating specialist

• 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

$25 per visit to your primary care provider

$45 per visit to a participating specialist

20% of the contracted rate (calendar year deductible applies)

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

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

$300 a day for the first three days per admission

(Calendar year deductible applies)

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

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

$300 per visit

(Calendar year deductible applies)

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

• Drugs and medications that by Federal law of the United States require a physician’s prescription for their purchase, except those listed as Not covered.
• Insulin
• Diabetic supplies limited to:
  - Disposable needles and syringes for the administration of covered medications
• Drugs for sexual dysfunction
• Growth hormone medication
• Drugs to treat gender dysphoria
• Fertility drugs associated with Artificial insemination procedures and IVF-related drugs for three cycles (annually).

Note: Prior authorization required for sexual dysfunction drugs. Coverage is limited; contact AvMed for dose limits. You pay the corresponding drug coinsurance up to the dosage limit and all charges above that.

Note: Growth hormone therapy is covered under the medical benefit.

Note: We only cover growth hormone medication when we preauthorize the treatment. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment. We will only cover GHT services and related services and supplies that we determine are medically necessary. See Other services under You need prior Plan approval for certain services on page 19. Please refer to your provider directory for a list of authorized providers for this treatment or contact us at 888-882-8633. 

Note: Opioid medications are covered under a quantity limit of 90 Morphine Milligram Equivalent (MME) per 30-day supply and a step therapy requirement for long acting opioids which require the use of a short-acting opioid first. As part of the prior authorization process, the Plan will provide advance warning to members approaching the MME quantity limit. There is also a 3-day limit on the initial fill for patients with acute conditions new to therapy with the option of up to a 7-day supply if deemed medically necessary by a physician.

Note: Your Specialty medication prescription coverage includes the quantity sufficient to treat the acute phase of an illness or established by the manufacturers packaging guidelines but not more than a 30-day supply per coinsurance or actual cost, whichever is less.

Note: We have an out-of-pocket maximum of $2,500 per member per calendar year on the Specialty medication benefit.

Note: Mail service is a benefit option for maintenance medications needed for chronic or long-term health conditions. It’s best to get an initial prescription filled at your retail pharmacy. Ask your physician for an additional prescription for up to a 90-day supply of your medication to be ordered through mail service. Pay the following copayment (as well as the cost difference if you or your physician choose a name Brand drug when there is an FDA-approved Generic).

Here are some things to keep in mind about our prescription drug program:

• When you have a prescription filled, a Generic equivalent to a name Brand drug will be dispensed. If you or your physician choose a name Brand drug when there is a FDA-approved Generic equivalent to that name Brand drug, you have to pay the difference in cost between the name Brand drug and the Generic drug plus the applicable Brand copayment. For name Brand drugs that do not have an FDA-approved Generic equivalent you will pay the applicable Brand copayment.

Retail Drugs (30-day supply)

$10 Generic Drugs (Tier 1)

$40 Preferred Brand Name Drugs (Tier 2)

$60 Non-Preferred Brand Name and Generic Drugs (Tier 3)

30% coinsurance Specialty Medication (Tier 4)

Mail Order Drugs (up to 90-day supply)

$30 Generic Drugs (Tier 1)

$120 Preferred Brand Name Drugs (Tier 2)

$180 Non-Preferred Brand Name and Generic Drugs (Tier 3)

Specialty drugs are not covered under Mail Order.

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

• Medical foods

Note: Medical foods are foods that are specifically formulated and intended for the dietary management of a disease that has distinctive nutritional needs that cannot be met by normal diet alone. Prescription is required. 

Note: Coverage is limited to inborn errors of metabolism and limited to $2,500 per calendar year.

20% of the contracted rate (calendar year deductible applies)

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.

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

• The contraceptive exception process may be initiated by a member’s prescribing provider or by the member. Providers must submit information to support the request to AvMed by fax to 877-535-1391 using the Medication Exception Request Form. Members may initiate the process by contacting the Member Engagement Center directly at 800-882-8633 and providing the prescriber’s complete information and any pertinent information related to the request. Members may also initiate the process using the Medication Exception Request Form. The Medication Exception Request Form is available at:  commercial-medication-exception-request-form.pdf (avmed.org).
• Reimbursement for over-the-counter contraceptives can be submitted by completing a claim form including the required information described in Section 7. Members may also contact the Member Engagement Center at 800-882-8863 for more information.

Note: Over-the-counter and prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation programs benefit (See page 38 "Educational classes and programs")

Nothing

Not covered:

• Drugs and supplies for cosmetic purposes.
• Drugs to enhance athletic performance.
• Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies.
• Vitamins, nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them.
• Non-prescription medications or medications for which there is a non-prescription alternative unless specifically indicated elsewhere.
• Medical supplies, including therapeutic devices, dressings, antiseptics, appliances, and support garments.
• Compounded prescriptions, except pediatric preparations.
• Prescription and non-prescription appetite suppressants and products for the purpose of weight loss.
• Medications for non-business related travel, including transdermal scopolamine, i.e. motion sickness patches.
• Replacement prescription products resulting from a lost, stolen, expired, broken, or destroyed prescription orders for refill.
• Medications that require preauthorization and for which preauthorization is denied or not obtained by a physician.
• Medications for dental purposes, including fluoride medications, antibiotics and pain medications for dental care.

All charges

The following drugs and supplements are covered, even if over-the-counter, if prescribed by a healthcare professional and filled at a network pharmacy. 

• Aspirin (81 mg) for men 45-79 and women age 55-79 and women of childbearing age. 
• Folic acid supplements for women of childbearing age 400 & 800 mcg
• Liquid iron supplements for child age 0-1 year
• Vitamin D supplements (prescription strength) (400 & 1000 units) for members 65 or older
• Fluoride tablets, solution (not toothpaste, rinses) for children age 0-6
• Statin use for the Primary Prevention of Cardiovascular Disease for adults aged 40 to 75 years with no history of CVD, 1 or more CVD risk factors, and a calculated 10-year CVD event risk of 10% or greater
• Naloxone-based rescue agents for the prevention of opioid overdose related deaths

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

Note: Over-the-counter and prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation programs benefit (See page 38 "Educational classes and programs").

Nothing

Not covered:

• Drugs and supplies for cosmetic purposes.
• Drugs to enhance athletic performance.
• Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies.
• Vitamins, nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them.
• Non-prescription medications or medications for which there is a non-prescription alternative unless specifically indicated elsewhere.
• Medical supplies, including therapeutic devices, dressings, antiseptics, appliances, and support garments.
• Compounded prescriptions, except pediatric preparations.
• Prescription and non-prescription appetite suppressants and products for the purpose of weight loss.
• Medications for non-business related travel, including transdermal scopolamine, i.e. motion sickness patches.
• Replacement prescription products resulting from a lost, stolen, expired, broken, or destroyed prescription orders for refill.
• Medications that require preauthorization and for which preauthorization is denied or not obtained by a physician.
• Medications for dental purposes, including fluoride medications, antibiotics and pain medications for dental care.

All charges

We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury.

We have no other dental benefits.

All charges

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

After you have paid the Plan’s deductible, we pay benefits under traditional medical coverage described in Section 5.   The Plan typically pays 80% for in-network and 0% 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 use disorder benefits
• Prescription drug benefits
• Dental benefits

Health Savings Accounts or Health Reimbursement Arrangements provide a means to help you pay out-of-pocket expenses (see 72 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 Service (IHS) benefits within the last three months or do not have other health insurance coverage other than another High Deductible Health Plan (HDHP). In 2024, for each month you are eligible for an HSA premium pass through, we will contribute to your HSA $62.51 per month for a Self Only enrollment or $62.51 per month for a Self Plus One enrollment or $62.51 per month 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 $3,600 for an individual and $7,200 for a family. See maximum contribution information on page 69. You can use funds in your HSA to help pay your health plan deductible. You own your HSA, so the funds can go with you if you change plans or employment.

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

HSA features include: 

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

Important consideration if you want to participate in a Healthcare Flexible Spending Account (HCFSA): If you are enrolled in this HDHP with a Health Savings Account (HSA), and start or become covered by a HCFSA healthcare flexible spending account (such as FSAFEDS offers – see Section 3), 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, for example, you are enrolled in Medicare or have another health plan, we will administer and provide an HRA instead. You must notify us that you are ineligible for an HSA.

In 2024, we will give you an HRA credit of $750 per year for a Self Only enrollment or $750 per year for a Self Plus One enrollment or $750 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 HealthEquity.
• Entire HRA credit (prorated from your effective date to the end of the plan year) is available from your effective date of enrollment.
• Tax-free credit can be used to pay for qualified medical expenses for you and any individuals covered by this HDHP.
• Unused credits carryover from year to year.
• HRA credit does not earn interest.
• HRA credit is forfeited if you leave Federal employment or switch health insurance plans.
• An HRA does not affect your ability to participate in an FSAFEDS Healthcare Flexible Spending Account (HCFSA). However, you must meet FSAFEDS eligibility requirements.

When you use network providers, your annual maximum for out-of-pocket expenses (deductibles, coinsurance and copayments) for covered services is limited to $4,000 per person or $6,750 per Self Plus One enrollment or, $6,750 Self and Family enrollment. However, certain expenses do not count toward your out-of-pocket maximum and you must continue to pay these expenses once you reach your out-of-pocket maximum (such as expenses in excess of the Plan’s allowable amount or benefit maximum). Refer to Section 4 Your catastrophic protection out-of-pocket maximum and HDHP Section 5 Traditional medical coverage subject to the deductible for more details.

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.

The Plan will establish an HSA for you with HealthEquity, this HDHP’s fiduciary (an administrator, trustee or custodian as defined by Federal tax code and approved by IRS.)

HealthEquity is the HRA fiduciary for this Plan.

Set-up fee is paid by the HDHP.

$0 per month administrative fee charged by the fiduciary and taken out of the account balance until it reaches $0.

None.

You must:

• Enroll in this HDHP
• Have no other health insurance coverage (does not apply to specific injury, accident, disability, dental, vision or long-term 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 Service (IHS) benefits in the last three months

Complete and return all banking paperwork

You must enroll in this HDHP.

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

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

Note: If your effective date in the HDHP is after the 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, My Pay, 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 2024, a monthly premium pass through of $62.51 will be made by the HDHP directly into your HSA each month.

For 2024, your HRA annual credit is $750 (prorated for mid-year enrollment).

For 2024, a monthly premium pass through of $62.51 will be made by the HDHP directly into your HSA each month.

For 2024, your HRA annual credit is $750 (prorated for mid-year enrollment).

For 2024, a monthly premium pass through of $62.51 will be made by the HDHP directly into your HSA each month.

For 2024, your HRA annual credit is $750 (prorated for mid-year enrollment).

The maximum that can be contributed to your HSA is an annual combination of HDHP premium pass through and enrollee contribution funds, which when combined, do not exceed the maximum contribution amount set by the IRS of $3,600 for an individual and $7,200 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 HDHP HSA (rollover funds do not affect your annual maximum contribution under this HDHP).

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

Additional contribution discussed on page 72.

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

You may make an annual maximum contribution of $2,850.

You cannot contribute to the HRA.

You may make an annual maximum contribution of $6,450.

You cannot contribute to the HRA.

You may make an annual maximum contribution of $6,450.

You cannot contribute to the HRA.

You can access your HSA by the following methods:

HealthEquity Visa Debit Card

Online Access to your personal account

Direct Pay a Provider

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, such as orthodontia, a reimbursement form will be sent to you upon your request.

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

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

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).

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

The fiduciary sends you HSA paperwork for you to complete and the fiduciary receives the completed paperwork back from you.

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

FEHB enrollee

HDHP

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 66, Section 5. HDHP Benefits Overview, "Health Savings Accounts (HSAs)" 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 may contribute, subtract the amount the Plan will contribute to your account for the year from the maximum contribution amount set by the IRS. You have until April 15 of the following year to make HSA contributions for the current year.

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

If you are age 55 or older, the IRS permits you to make additional contributions to your HSA. The allowable additional contribution is $1,000. Contributions must stop once an individual is enrolled in Medicare. Additional details are available on the IRS website at https://www.irs.gov or request a copy of IRS Publication 969 by calling 1-800-829-3676.

If you have not named beneficiary and you are married, your HSA becomes your spouse’s; otherwise, your HSA 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, physician prescribed over-the-counter drugs, LASIK surgery, and some nursing services.

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

For a detailed list of IRS-allowable expenses, request a copy of IRS Publication 502 by calling 1-800-829-3676, or visit the IRS website at www.irs.gov and click on “Forms and Publications.” Note: Although physician prescribed over-the-counter drugs are not listed in the publication, they are reimbursable from your HSA. Also, insurance premiums are reimbursable under limited circumstances.

You may withdraw money from your HSA for items other than qualified health expenses, but it will be subject to income tax and if you are under 65 years old, 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, as long as there are fund available in your HSA.

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 on page 68 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.

Professional services, such as:

• Routine physicals
• Routine screenings
• Routine immunizations endorsed by the Centers for Disease control and Prevention (CDC)
• Routine prenatal care
• Tobacco Cessation programs
• Obesity weight loss programs
• Disease management programs

Nothing

Routine physical annually

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

• Immunizations such as Pneumococcal, influenza, shingles, tetanus/Tdap, and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at:
  https://www.cdc.gov/vaccines/schedules
• Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening.  For a complete list of screenings, go to the
  U.S. Preventive Service Task Force (USPTF) website at:
  https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
• Individual counseling on prevention and reducing health risks
• Preventive care benefits for women such as Pap smears, gonorrhea, prophylactic medications to protect newborns, annual counseling for sexually transmitting infections, contraceptive methods, and screening for interpersonal and domestic violence.  For a complete list of preventive care benefits for women go to the Health and Human Services (HHS) website at:
  https://www.healthcare.gov/preventive-care-women
• To build your personalized list of preventive services go to: https://health.gov/myhealthfinder

Nothing

• Routine Prostate Specific Antigen (PSA) test - one annually for men age 40 and older
• Mammograms (Routine and non-routine)
• Adult Immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule
• Medical Nutrition Therapy and Intensive Behavioral Therapy for the prevention of obesity related comorbidities as recommended under the U.S. Preventive Services Task Force (USPSTF A and B recommendations.

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

Nothing

Not covered:

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

All charges

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

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

Note: A complete list of preventive care services recommended under the U.S. Preventive Services Task Force is available (USPSTF) is available online at:
www.uspreventiveservicestaskforce.org

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

ACIP recommendations on immunizations, please refer to the National Immunization Program Web site at:
www.cdc.gov/vaccines/schedules/index.html

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

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

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

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

Nothing

Not covered:

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

All charges

The deductible applies to almost all benefits in this Section. In the You pay column, we say “(deductible does not apply)” when it does not apply. When you receive covered services from network providers, you are responsible for paying the allowable charges until you meet the deductible.

100% of allowable charges until you meet the deductible of $1,600 per person, $3,200 per Self Plus One enrollment or $3,200 per Self and Family enrollment.

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

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

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

Professional services of physicians:

• In physician’s office
• In an urgent care center
• During a hospital stay
• In a skilled nursing facility
• Office medical consultations
• Second surgical opinion
• At home
• Advance care planning

20% of the contracted rate 

Note: AvMed's Telehealth Services provide anytime remote access to board-certified doctors from your home, your office, or on the go. Just 15 minutes after a simple sign-up, Members can speak with a doctor about non-emergency medical issues by phone or by secure video using a computer, tablet, or smartphone.

Nothing (deductible does not apply)

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine pap tests
• Pathology
• X-rays
• CT/CAT Scans
• PET Scans
• MRI
• Ultrasound
• Electrocardiogram and EEG

20% of the contracted rate 

Complete maternity (obstetrical) care, such as:

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

20% of the contracted rate 

Breastfeeding support, supplies and counseling for each birth

Nothing (deductible does not apply)

Note: Here are some things to keep in mind:

• You do not need to precertify your vaginal delivery; see pages 20 and 21, Section 3. How You Get Care, "How to request precertification for an admission or get prior authorization for Other services" for other circumstances, such as extended stays for you or your baby.
• You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary.
• We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or a Self and Family enrollment. Surgical benefits, not maternity benefits, apply to circumcision.
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).

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

Contraceptive counseling on an annual basis

Nothing (deductible does not apply)

A range of voluntary family planning services, limited to:

• Voluntary sterilization (e.g., tubal ligation, vasectomy) See surgical procedures Section 5(b)
• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo Provera)
• Intrauterine devices (IUDs)
• Diaphragms
• Genetic testing

Note: All genetic testing requests will be reviewed for medical necessity.

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

Nothing (deductible does not apply)

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic counseling

All charges

Diagnosis and treatment of infertility such as:

• Artificial insemination:
  • Intravaginal insemination (IVI)
  • Intracervical insemination (ICI)
  • Intrauterine insemination (IUI)
• Medically necessary hormone testing
• Semen analysis
• Sperm function testing
• Chromosomal analysis
• Medical imaging
• Surgical correction of genitourinary tract abnormalities
• Fertility preservation for Iatrogenic Infertility

20% of the contracted rate 

• Fertility drugs

See Section 5(f)

Note: Infertility is defined as the inability of an individual to achieve conception after one year for individuals under age 35 and six months for individuals age 35 and older; or the inability of an individual to achieve conception after egg-sperm contact through the use of artificial insemination. Infertility may also be established through an evaluation based on medical history and diagnostic testing.

Not covered:

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

All charges

• Testing and treatment
• Allergy injections
• Allergy serum

20% of the contracted rate 

Not covered:

• Provocative food testing and sublingual allergy desensitization

All charges

• Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on page 90.

• Respiratory and inhalation therapy
• Cardiac rehabilitation following qualifying event/condition is provided for up to 18 sessions.
• 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.

Note: We only cover GHT when we preauthorize the treatment. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment. We will only cover GHT services and related services and supplies that we determine are medically necessary. See Other services under You need prior Plan approval for certain services on page 19.  Please refer to your provider directory for a list of authorized providers for this treatment or contact us at 888-882-8633.

20% of the contracted rate 

Short-term therapy for acute condition for which therapy applied for a consecutive two calendar month period (per condition) can be expected to result in significant improvements for 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 medically necessity for skilled services; and
• indicates the length of time the services are needed.

20% of the contracted rate 

Not covered:

• Long-term rehabilitative therapy
• Exercise programs

All charges

Short-term speech therapy, when medically necessary, for acute condition for which therapy applied for a consecutive two calendar month period (per condition) can be expected to result in significant improvement.

20% of the contracted rate 

Coverage for Habilitative Services is covered the same as physical, occupational and speech therapy and includes services for Applied Behavior Analysis.

20% of the contracted rate 

• 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. Preventive Care, children.

Nothing (deductible does not apply)

• External hearing aids (limited to $3,000 per year) and testing to fit them
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants

Note: For benefits for the devices, see HDHP Section 5. Preventive Care, children. 

20% of the contracted rate 

Not covered:

• Hearing services that are not shown as covered

All charges

• Annual eye refractions to determine the need for vision correction for children through age 17
• Diagnosis and treatment of diseases of the eye

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

20% of the contracted rate 

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

20% of the contracted rate 

Not covered:

• All other vision testing (eye examinations and refractions)
• Eyeglasses or contact lenses (including replacement of lenses provided during the same calendar year)
• Eye exercises and orthoptics
• Radial keratotomy and other refractive surgery

All charges

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

20% of the contracted rate 

Not covered:

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

All charges

• Artificial limbs and eyes
• Prosthetic sleeve and sock
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.
• External hearing aids and testing to fit them (External hearing aids limited to $3,000 per year)
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants
• Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy.

Note: For information on the professional charges for the surgery to insert an implant, see Section 5(b) Surgical 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.

20% of the contracted rate 

Not covered:

• Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups
• Non orthopedic base
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Penile implants
• Prosthetic replacements provided less than 3 years after the last one we covered

All charges

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

• Oxygen
• Dialysis equipment
• Hospital beds
• Standard Wheelchairs
• Crutches
• Walkers
• Insulin pumps
• Ostomy and catheter supplies

Note: Coverage for orthotic appliances is limited to leg, arm, back, and neck custom-made braces when related to a surgical procedure or when used in an attempt to avoid surgery and are necessary to carry out normal activities of daily living, excluding sports activities.  Coverage is limited to the first such item; repair and replacement is not covered.

Note: Call us at 888-882-8633 as soon as your Plan physician prescribes this equipment. We will arrange with a healthcare provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

20% of the contracted rate 

Not covered:

• Medical supplies such as corsets which do not require a prescription
• Audible prescription reading devices
• Speech generating devices
• Motorized wheelchairs
• Non-standard wheelchairs
• All other orthotic appliances

All charges

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

20% of the contracted rate 

Not covered:

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

All charges

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

20% of the contracted rate 

No benefit

All charges

Coverage is provided for:

• Tobacco Cessation programs, including individual/group/telephone counseling, and for over the counter (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.

(deductible does not apply)

• Diabetes self management

20% of the contracted rate 

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

Nothing (deductible does not apply)

A comprehensive range of services, such as:

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

Note: Morbid Obesity is a condition in which an individual weighs 100 pounds or 100% over his or her normal weight according to current underwriting standards; eligible members must be age 18 or over. 1. Weight loss surgery may be an option for a select group of patients with clinically severe obesity or morbid obesity. When non-evasive methods of weight reduction have been exhausted, surgery will be considered for individuals with a Body Mass Index (BMI) of greater than or equal to 40 or a BMI of 35 or greater, with coexisting conditions.

Individuals may qualify for surgery if they have been morbidly obese for a period of five (5) years or more. Morbid obesity is defined as having a BMI in excess of 40 or a BMI in excess of 35 with any of the following severe co-morbidities: coronary heart disease, diabetes mellitus, clinically significant obstructive sleep apnea, and medically refractory hypertension; 2. Member has completed growth (18 years of age or documentation of bone growth completion); 3. Recent psychiatric/psychological evaluation to rule out eating disorder(s) or psychological disturbance, such as Binge Eating Disorder, active drug abuse, active suicidal ideations/thoughts, borderline personality disorder, schizophrenia, terminal illness or uncontrolled depression, which may impede post-operative recovery and dietary restrictions; 4. Documentation (e.g., type, duration, amount of weight loss) of all prior weight control/loss programs including: food supplements, appetite suppressants, dietary regimens/treatments, and exercise programs; 5. Documentation of non-operative, physician supervised integrated weight reduction program consisting of dietary therapy, appropriate exercise, behavior modification and psychological support: Four (4) physician visits are required over a six (6) month period to document supervision; the program must maintain at least a six (6) month duration, within three (3) years of request for surgical intervention.

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

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

• Treatment of burns

20% of the contracted rate 

• Voluntary sterilization (e.g. tubal ligation, Vasectomy)

Nothing (deductible does not apply)

Not covered:

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

All charges

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
  • the condition produced a major effect on the member’s appearance and
  • the condition can 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; birthmarks; and webbed fingers and toes.
• All stages of breast reconstruction surgery following a mastectomy, such as:
  • surgery to produce a symmetrical appearance of breasts
  • treatment of any physical complications, such as lymphedemas
  • breast prostheses and surgical bras and replacements (see Prosthetic devices)

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

• Gender affirming surgery including, but not limited to, mastectomy, gonadectomy (hysterectomy and oophorectomy in female-to-male and orchiectomy in male-to-female), and genital reconstruction (in female-to-male: vaginectomy, urethroplasty, metoidioplasty, phalloplasty, scrotoplasty, and placement of a testicular and erectile prosthesis; in male-to-female: penectomy, vaginoplasty, labiaplasty, and clitoroplasty).
• Feminizing procedures including, but not limited to, Rhinoplasty, face-lifting, lip enhancement, facial bone reduction, blepharoplasty, breast augmentation, liposuction of the waist (body contouring), reduction of hyoid (chondroplasty), hair removal, voice modification surgery (laryngoplasty or shortening of the vocal cords), and skin resurfacing.
• Masculinizing procedures including, but not limited to, chin implants, nose implants, and lip reduction. In addition, Abdominoplasty, brow lift, calf implants, cheek/malar implants, chin/noseimplants, collagen injections, liposuction, mastopexy, and pectoral implants.

20% of the contracted rate 

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.
• Procurement, cryopreservation or storage of embryo, sperm, oocytes for the preservation of fertility and the cryopreservation, storage, and thawing of reproductive tissue (i.e., ovaries, testicular tissue).

All charges

Oral surgical procedures, limited to:

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

20% of the contracted rate 

Not covered:

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

All charges

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

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

Note: Subject to medical necessity and experimental/investigational review by the Plan. See Other services under You need prior Plan approval for certain services on page 16. The medical necessity limitation is considered satisfied for other tissue transplants if the patient meets the staging description and can safely tolerate the procedure.

20% of the contracted rate 

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

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

20% of the contracted rate 

Hematopoietic stem cell or blood marrow transplants

The Plan extends coverage for the diagnoses as indicated below.

• Allogeneic transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced neuroblastoma
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Aplastic anemia
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Infantile malignant osteopetrosis
  • Kostmann’s syndrome
  • Leukocyte adhesion deficiencies
  • Marrow failure and related disorders (i.e., Fanconi’s, PNH, 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
  • Myeloproliferative disorders
  • Paroxysmal Nocturnal Hemoglobinuria
  • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
  • Sickle cell anemia
  • X-linked lymphoproliferative syndrome
• Autologous transplants for:
  • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Breast Cancer
  • Ependymoblastoma
  • Epithelial Ovarian Cancer
  • Ewing’s sarcoma
  • Medulloblastoma
  • Multiple myeloma
  • Neuroblastoma
  • Pineoblastoma
  • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors
  • Waldenstrom's macroglobulinemia
• Autogolous tandem transplants for recurrent germ cell tumors (including testicular cancer)

Note:  Treatment must be approved by the Plan's medical director in accordance with the Plan's protocols.  AvMed will request the medical evidence we need to make our coverage determination.

20% of the contracted rate 

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

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

• Allogeneic transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Breast Cancer
  • Chronic lymphocytic leukemia
  • Chronic lymphocytic leukemia/ small lymphocytic lymphoma (CLL/SLL) relapsed/refractory disease
  • Chronic myelogenous leukemia
  • Colon cancer
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Hemoglobinopathy
  • Marrow failure and related disorders (i.e., Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)
  • Multiple Myeloma
  • Multiple Sclerosis
  • Myleoproliferative Disorders
  • Myelodysplasia/Myelodysplastic syndromes
  • Non-small cell lung cancer
  • Ovarian cancer
  • Paroxysmal Nocturnal Hemoglobinuria
  • Prostate cancer
  • Renal cell carcinoma
  • Sarcomas
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
  • Sickle cell disease

• Autologous transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic myelogenous leukemia
  • Chronic lymphocytic lymphoma/ small lymphocytic lymphoma (CLL/SLL)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Neuroblastoma
  • Small cell lung cancer

• Autologous transplants for the following autoimmune diseases:
  • Multiple sclerosis
  • Scleroderma
  • Scleroderma-SSc(severe, progessive)
  • Systemic lupus erythematosus
  • Systemic sclerosis

20% of the contracted rate 

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

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

Hematopoietic stem cell or bone marrow transplants

The Plan extends coverage for the diagnoses as indicated below:

• Allogeneic transplants for:
• Beta Thalassemia Major
• Chronic Inflammatory Demyelinating Polyneuropathy (CIDP)
• Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
• Multiple myeloma
• Multiple sclerosis
• Sickle Cell anemia
• Autologous transplants for:
• Advanced Childhood kidney cancers
• Advanced Ewing sarcoma
• Aggressive non-Hodgkin’s lymphomas (Mantle Cell lymphoma, adult T-cell leukemia/lymphoma, peripheral T-cell lymphomas and aggressive Dendritic Cell neoplasms
• Breast Cancer
• Childhood rhabdomyosarcoma
• Epithelial Ovarian Cancer 
• Mantle Cell (Non-Hodgkin lymphoma)

Note:  Treatment must be approved by the Plan's medical director in accordance with the Plan's protocols.  AvMed will request the medical evidence we need to make our coverage determination.

20% of the contracted rate

Not covered:

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

All charges

Professional services provided in –

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

20% of the contracted rate 

Room and board, such as

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

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

20% of the contracted rate 

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and X-rays
• Blood or blood plasma, if not donated or replaced
• Dressings, splints, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services
• Take-home items
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home (Note: calendar year deductible applies.)

20% of the contracted rate 

Not covered:

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

All charges

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

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.  If you have outpatient surgery and it turns into Observation care that exceeds 24 hours, only outpatient surgery cost share will apply.

20% of the contracted rate 

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

All charges

Extended care benefit:

We provide a comprehensive range of benefits for up to 30 post-hospital days per calendar year when full-time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan. All necessary services are:

• 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

20% of the contracted rate 

Not covered: Custodial care

All charges

We provide supportive and palliative care for a terminally ill member in the home or hospice facility. Services include:

• Inpatient and outpatient care;
• Family counseling

Note: These services are provided under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness, with a life expectancy of approximately six months or less.

20% of the contracted rate 

Not covered: Independent nursing, homemaker services

All charges

Local professional ambulance service including air ambulance, when medically appropriate and ordered or authorized by a Plan doctor. 

20% of the contracted rate 

• Emergency care at a doctor’s office
• Emergency care at a participating urgent care center
• Emergency care at a non-participating urgent care center
• Emergency care at a hospital emergency room

Note: We waive the ER copay if you are admitted to the hospital.  If you go through the Emergency Room and need to stay for Observation care which exceeds 24 hours, only the ER cost share will apply.

20% of the contracted rate 

Not covered: Elective care or non-emergency care

All charges

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

Note: We waive the ER copay if you are admitted to the hospital. If you go through the Emergency Room and need to stay for Observation care which exceeds 24 hours, only the ER cost share will apply.

20% of the contracted rate 

Not covered:

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

All charges

• Professional ambulance service when medically appropriate.
• Air ambulance, when medically necessary and preauthorized by Medical Director of Chief Medical Officer. 

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

20% of the contracted rate 

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

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

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

• Diagnostic evaluation
• Crisis intervention and stabilization for acute episodes
• Medication evaluation and management (pharmacotherapy)
• Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
• Treatment and counseling (including individual or group therapy visits)
• Diagnosis and treatment of 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
• Applied Behavioral Analysis services

20% of the contracted rate

• 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

20% of the contracted rate 

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

20% of the contracted rate 

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

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

20% of the contracted rate 

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

• Drugs and medications that by Federal law of the United States require a physician’s prescription for their purchase, except those listed as Not covered.
• Insulin
• Diabetic supplies limited to:
  - Disposable needles and syringes for the administration of covered medications
• Drugs for sexual dysfunction 
• Growth hormone medication
• Drugs to treat gender dysphoria
• Fertility drugs associated with Artificial insemination procedures and IVF-related drugs for three cycles (annually).

Note: Prior authorization required for sexual dysfunction drugs. Coverage is limited; contact AvMed for dose limits. You pay the corresponding drug copayment up to the dosage limit and all charges above that.

Note: Growth hormone therapy is covered under the medical benefit.

Note: We only cover growth hormone medication when we preauthorize the treatment. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment. We will only cover GHT services and related services and supplies that we determine are medically necessary. See Other services under You need prior Plan approval for certain services on page 19. Please refer to your provider directory for a list of authorized providers for this treatment or contact us at 888-882-8633.

Note: Opioid medications are covered under a quantity limit of 90 Morphine Milligram Equivalent (MME) per 30-day supply and a step therapy requirement for long acting opioids which require the use of a short-acting opioid first.  As part of the prior authorization process, the Plan will provide advance warning to members approaching the MME quantity limit.  There is also a 3-day limit on the initial fill for patients with acute conditions new to therapy with the option of up to a 7-day supply if deemed medically necessary by a physician.

Note: Your Specialty medication prescription coverage includes the quantity sufficient to treat the acute phase of an illness or established by the manufacturer's packaging guidelines but not more than a 30 day supply per copayment or actual cost, whichever is less.

Note: Mail service is a benefit option for maintenance medications needed for chronic or long-term health conditions. It’s best to get an initial prescription filled at your retail pharmacy. Ask your physician for an additional prescription for up to a 90-day supply of your medication to be ordered through mail service. Pay the following copayment (as well as the cost difference if you or your physician choose a name Brand drug when there is an FDA-approved Generic).

Here are some things to keep in mind about our prescription drug program:

• When you have a prescription filled, a Generic equivalent to a name Brand drug will be dispensed. If you or your physician choose a name Brand drug when there is a FDA-approved Generic equivalent to that name Brand drug, you have to pay the difference in cost between the name Brand drug and the Generic drug plus the applicable Brand copayment. For name Brand drugs that do not have an FDA-approved Generic equivalent you will pay the applicable Brand copayment.

Retail Drugs (30-day supply)

$10 Generic Drugs (Tier 1)

$30 Preferred Brand Name Drugs (Tier 2)

$50 Non-Preferred Brand Name and Generic Drugs (Tier 3)

$75 Specialty Medication (Tier 4)

Mail Order Drugs (up to a 90-day supply)

$30 Generic Drugs (Tier 1)

$90 Preferred Brand Name Drugs (Tier 2)

$150 Non-Preferred Brand Name and Generic Drugs (Tier 3)

Specialty drugs are not covered under Mail Order

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

• Medical foods

Note: Medical foods are foods that are specifically formulated and intended for the dietary management of a disease that has distinctive nutritional needs that cannot be met by normal diet alone. Prescription is required.

Note: Coverage is limited to inborn errors of metabolism and limited to $2,500 per calendar year.

20% of the contracted rate 

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.

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

• The contraceptive exception process may be initiated by a member’s prescribing provider or by the member. Providers must submit information to support the request to AvMed by fax to 877-535-1391 using the Medication Exception Request Form. Members may initiate the process by contacting the Member Engagement Center directly at 800-882-8633 and providing the prescriber’s complete information and any pertinent information related to the request. Members may also initiate the process using the Medication Exception Request Form. The Medication Exception Request Form is available at: commercial-medication-exception-request-form.pdf (avmed. org).
• Reimbursement for over-the-counter contraceptives can be submitted by completing a claim form including the required information described in Section 7. Members may also contact the Member Engagement center at 800-882-8863 for more information.

Nothing

Note: Over-the-counter and prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation programs benefit and we require a written prescription by an approved provider. (See page 84, "Educational classes and programs")

Nothing

Not covered:

• Drugs and supplies for cosmetic purposes.
• Drugs to enhance athletic performance.
• Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies.
• Vitamins, nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them.
• Non-prescription medications or medications for which there is a non-prescription alternative unless specifically indicated elsewhere.
• Medical supplies, including therapeutic devices, dressings, antiseptics, appliances, and support garments.
• Compounded prescriptions, except pediatric preparations.
• Prescription and non-prescription appetite suppressants and products for the purpose of weight loss.
• Medications for non-business related travel, including transdermal scopolamine, i.e. motion sickness patches.
• Replacement prescription products resulting from a lost, stolen, expired, broken, or destroyed prescription orders for refill.
• Medications that require preauthorization and for which preauthorization is denied or not obtained by a physician.
• Medications for dental purposes, including fluoride medications, antibiotics and pain medications for dental care.

All charges

The following drugs and supplements are covered, even if over-the-counter, if prescribed by a healthcare professional and filled at a network pharmacy.

• Aspirin (81 mg) for men 45-79 and women age 55-79 and women of childbearing age.
• Folic acid supplements for women of childbearing age 400 & 800 mcg
• Liquid iron supplements for child age 0-1 year
• Vitamin D supplements (prescription strength) (400 & 1000 units) for members 65 or older
• Fluoride tablets, solution (not toothpaste, rinses) for children age 0-6
• Statin use for the Primary Prevention of Cardiovascular Disease for adults aged 40 to 75 years with no history of CVD, 1 or more CVD risk factors, and a calculated 10-year CVD event risk of 10% or greater.
• Naloxone-based rescue agents for the prevention of opioid overdose related deaths.

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

Note: Over-the-counter and prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation programs benefit (See page 84 "Educational classes and programs").

Nothing

Not covered:

• Drugs and supplies for cosmetic purposes.
• Drugs to enhance athletic performance.
• Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies.
• Vitamins, nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them.
• Non-prescription medications or medications for which there is a non-prescription alternative unless specifically indicated elsewhere.
• Medical supplies, including therapeutic devices, dressings, antiseptics, appliances, and support garments.
• Compounded prescriptions, except pediatric preparations.
• Prescription and non-prescription appetite suppressants and products for the purpose of weight loss.
• Medications for non-business related travel, including transdermal scopolamine, i.e. motion sickness patches.
• Replacement prescription products resulting from a lost, stolen, expired, broken, or destroyed prescription orders for refill.
• Medications that require preauthorization and for which preauthorization is denied or not obtained by a physician.
• Medications for dental purposes, including fluoride medications, antibiotics and pain medications for dental care.

All charges

We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth. The need for these services must result from an accidental injury.

20% of the contracted rate 

We have no other dental benefits

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

For any of your health concerns, 24 hours a day, 7 days a week, you may call 888-866-5432 and talk with a registered nurse who will discuss treatment options and answer your health questions.

Consult the Member Engagement Center, at 800-882-8633 to obtain a complete list of centers.

As part of our Healthy Living Programs, AvMed provides Disease Management for the following conditions:

• COPD (Chronic Obstructive Pulmonary Disease)
• CAD (Coronary Artery Disease)
• Heart failure
• Diabetes
• Asthma

You may call us at 855-812-8633 if you wish to learn more about our Disease Management programs.

AvMed has a comprehensive and engaging Wellness Program that will assist you to embrace better health.  The program provides you with online tools that include a Personal Health Assessment (PHA), a personal Scorecard detailing your health status, e-courses, health centers and a printable library with additional self-management tools to enhance your healthy living.  The Wellness Program can help you with:

• Changing health risks, with and without a chronic illness
• Weight management (nutrition and exercise)
• Tobacco cessation
• Stress management
• Pre-diabetes
• Metabolic syndrome
• Sleep

In addition, through our partnerships we provide you with:

• Weight Watchers discounts and reimbursements
• The ChooseHealthy Program: where you can get up to 25% off services from more than 33,000 contracted chiropractors, acupuncturists, massage therapists and registered dieticians.  You can also shop from an online catalog of discounted health and wellness products, all with free shipping.

Log onto our website at www.avmed.org to access the Wellness Program.  Click on Health and Wellness, and find all these resources and more under Tools for a Healthier You.

Every AvMed member has a friend in our Member Engagement Center, we are open Monday - Friday from 8 a.m. to 8 p.m. and on Saturdays from 9 a.m. to 1 p.m. Representatives are here for you to answer questions regarding benefits, claims, changing physicians – anything involving your AvMed membership. Next to healthcare coverage itself, every satisfaction survey tells us this is every member’s most valued service. Contact them at members@avmed.org or call 800-882-8633.

We publish an e-newsletter to keep you informed on a variety of issues related to your good health.

Visit our website at www.AvMed.org for information on:

• General health topics
• Links to healthcare news
• Cancer and other specific diseases
• Drugs/medication interactions
• Kids’ health
• Patient safety information
• Several helpful website links

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

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

You will receive an EOB after every claim.

If you have an HSA:

- You will receive a statement outlining your account balance and activity for the month.

- You may also access your account on-line at www.AvMed.org.

If you have an HRA:

- Your HRA balance will be available online through www.AvMed.org.

- Your balance will also be shown on your EOB form.

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

Pricing information for medical care is available at www.AvMed.org. Pricing information for prescription drugs is available at www.AvMed.org.

Link to online pharmacy through www.AvMed.org.

Educational materials on the topics of HSAs, HRAs and HDHPs are available at www.AvMed.org.

Patient safety information is available online at www.AvMed.org.

Case Managers

AvMed has medically underwritten individual coverage plans available in Broward, Miami-Dade and Palm Beach Counties, Florida.  For more information call 800-390-9355 or visit our website at www.avmed.org/individual.

In most cases, providers and facilities file claims for you. Providers must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. For claims questions and assistance, contact us at 800-882-8633, or at our website at www.avmed.org.

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

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

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

Submit your claims to: 3470 NW 82nd Avenue, Doral, FL 33122, 800-882-8633, www.avmed.org

Submit your claims to: 3470 NW 82nd Avenue, Doral, FL 33122, 800-882-8633, www.avmed.org  

Submit your claims to:  3470 NW 82nd Avenue, Doral, FL 33122, 800-882-8633, www.avmed.org

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

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

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

You may designate an authorized representative to act on your behalf for filing a claim or to appeal claims decisions to us.  For urgent care claims, we will permit a healthcare professional with knowledge of your medical condition to act as your authorized representative without your express consent.   For the purposes of this section, we are also referring to your authorized representative when we refer to you.

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

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

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

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

b) Send your request to us at: AvMed Member Engagement Center, P.O. Box 569008, Gainesville, FL 33256-9908; and

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

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

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

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

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

a) Pay the claim or

b) Write to you and maintain our denial or

c) Ask you or your provider for more information

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

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

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

You must write to OPM within:

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

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

Send OPM the following information:

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

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

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

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

OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision or notify you of the status of OPM's review within 60 days. There are no other administrative appeals.

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

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

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

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

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

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

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

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

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

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

We do not cover services that:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 800-882-8633 or see our website at www.avmed.org.

We do not waive any costs if the Original Medicare Plan is your primary payer.

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

Benefit Description: Deductible
Standard Option You Pay without Medicare: $500 self only / $1,000 self and family
Standard Option You Pay with Medicare Part B: $500 self only / $1,000 self and family
HDHP Option You Pay without Medicare: $1,600 self only / $3,200 self and family
HDHP Option You Pay with Medicare Part B: $1,600 self only / $3,200 self and family

Benefit Description: Out-of-Pocket Maximum
Standard Option You Pay without Medicare: $4,500 self only / $9,000 self and family
Standard Option You Pay with Medicare Part B: $4,500 self only / $9,000 self and family
HDHP Option You Pay without Medicare: $4,000 self only / $6,750 self and family
HDHP Option You Pay with Medicare Part B: $4,000 self only / $6,750 self and family

Benefit Description: Part B Premium Reimbursement Offered
You receive without Medicare: NA
You receive with Medicare Part B: NA

Benefit Description: Primary Care Provider
Standard Option You pay without Medicare: $25
Standard Option You pay with Medicare Part B: $25
HDHP Option You pay without Medicare: 20% coinsurance (calendar year deductible also applies)
HDHP Option You pay with Medicare Part B: 20% coinsurance (calendar year deductible also applies)

Benefit Description: Specialist
Standard Option You pay without Medicare: $45
Standard Option You pay with Medicare Part B: $45
HDHP Option You pay without Medicare: 20% coinsurance (calendar year deductible also applies)
HDHP Option You pay with Medicare Part B: 20% coinsurance (calendar year deductible also applies)

Benefit Description: Inpatient Hospital
Standard Option You pay without Medicare: $300 a day for the first three days per admission
Standard Option You pay with Medicare Part B: $300 a day for the first three days per admission
HDHP Option You pay without Medicare: 20% coinsurance (calendar year deductible also applies)
HDHP Option You pay with Medicare Part B: 20% coinsurance (calendar year deductible also applies)

Benefit Description: Outpatient Hospital
Standard Option You pay without Medicare: $300 a day for the first three days per admission
Standard Option You pay with Medicare Part B: $300 copay per visit
HDHP Option You pay without Medicare: 20% coinsurance (calendar year deductible also applies)
HDHP Option You pay with Medicare Part B: 20% coinsurance (calendar year deductible also applies)

Benefit Description: Incentives Offered
You pay without Medicare:
You pay with Medicare Part B:

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private healthcare choices (like HMOs and regional PPOs) in some areas of the country. To learn more about Medicare Advantage plans, contact Medicare at 800-MEDICARE (800-633-4227) or at www.medicare.gov.

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

This Plan and our Medicare Advantage plan:  You may enroll in our Medicare managed care plan and also remain enrolled in our FEHB plan.  In this case, we do not waive any of our copayments for your FEHB coverage.

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

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

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

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

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

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

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

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

• Medicare was the primary payor before eligibility due to ESRD

• Medicare based on age and disability

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

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

An authorization by you (the enrollee or covered family member) that is approved by us (the Carrier), for us to issue payment of benefits directly to the provider.

• We reserve the right to pay you directly for all covered services. Benefits payable under the contract are not assignable by you to any person without express written approval from us, and in the absence of such approval, any assignment shall be void.
• Your specific written consent for a designated authorized representative to act on your behalf to request reconsideration of a claim decision (or, for an urgent care claim, for a representative to act on your behalf without designation) does not constitute an Assignment.
• OPM’s contract with us, based on federal statute and regulation, gives you a right to seek judicial review of OPM's final action on the denial of a health benefits claim but it does not provide you with authority to assign your right to file such a lawsuit to any other person or entity. Any agreement you enter into with another person or entity (such as a provider, or other individual or entity) authorizing that person or entity to bring a lawsuit against OPM, whether or not acting on your behalf, does not constitute an Assignment, is not a valid authorization under this contract, and is void.

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

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

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

See Section 4, page 22.

See Section 4, page 22.

See Section 4, page 22.

Services and supplies that are furnished mainly to train or assist in the activities of daily living, such as bathing, feeding, dressing, walking and taking oral medications. “Custodial Care” also means services and supplies that can be safely and adequately provided by persons other than licensed health care professionals, such as dressing changes and catheter care or that of ambulatory patients customarily provide for themselves, such as ostomy care, measuring and recording urine and blood sugar levels, and administering insulin. Custodial care that lasts 90 days or more is sometimes know as Long Term Care.

See Section 4, page 22.

The Plan’s experimental/investigational determination process is based on authoritative information from medical literature, medical consensus bodies, FDA approval, clinical trials, and health care professionals with specialty expertise in the subject.

The form of health insurance covering groups of persons under a master group health insurance policy issued to any one group.

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

The use of any appropriate medical treatment, service, equipment and/or supply as provided by a hospital, skilled nursing facility, physician or other provider which is necessary for the diagnosis, care and/or treatment of a Member’s illness or injury.

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

• Network Providers - we negotiate rates with doctors and other health care providers to help save you money. We refer to these providers as “Network Providers". These negotiated rates are our Plan allowance for network providers. We calculate a member’s coinsurance using these negotiated rates. The member is not responsible for amounts that are billed by network providers that are greater than our Plan allowance.
• You should also see Important Notice About Surprise Billing – Know Your Rights in Section 4 that describes your protections against surprise billing under the No Surprises Act.

An unexpected bill you receive for

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

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

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

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

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

If you believe your claim qualifies as an urgent care claim, please contact the Member Engagement Center at 800-882-8633.  You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

Office visit copay: $25 primary care; $45 specialist

28

$300 * per day for the first three days of admission up to a $900 maximum

49

$300 * per visit

50

$100 per visit (copayment waived if admitted)

53

$100 per visit (copayment waived if admitted)

53

Regular cost sharing

54

Generic $10, Preferred Brand $40, Non-Preferred Brand $60, Specialty medications 30% coinsurance

58

Generic $30, Preferred Brand $120, Non-Preferred Brand $180, No 4th Tier (Specialty drugs are not covered under Mail Order)

58

No benefit.

62

$45 per visit to a participating specialist

34

Special features described in Section 5(h).

110

Nothing after $4,500/Self only, $9,000 Self Plus One, or $9,000 Self and Family enrollment per year

Some costs do not count toward this protection

22

Nothing (deductible does not apply)

74

20% of the contracted rate

78

20% of the contracted rate

96

20% of the contracted rate

97

20% of the contracted rate

100

20% of the contracted rate

100

Regular cost sharing

101

Generic $10, Preferred Brand $30, Non- Preferred Brand $50, Specialty medications
$75

105

Generic $30, Preferred Brand $90, Non- Preferred Brand $150, No 4th Tier (Specialty drugs are not covered under Mail Order)

106

No benefit

109

20% of the contracted rate

83

Special features described in Section 5(h).

110

Nothing after $4,000/Self only, $6,750 Self Plus One and Self and Family enrollment per year

Some costs do not count toward this protection

22