• No pre-existing condition limitation

We will not refuse to cover the treatment of a condition you had before you enrolled in this Plan solely because you had the condition before you enrolled.

• Minimum essential coverage (MEC)

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.

• Minimum value standard

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.

• Where you can get information about enrolling in the FEHB Program

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, and give you brochures for other Plans, and other materials you need to make an informed decision about your FEHB coverage. These materials tell you:

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

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

• Types of coverage available for you and your family

Self Only coverage is for you alone. Self Plus One coverage is for you and one eligible family member. Self and Family coverage is for you, and one eligible family member, or 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.

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

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

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

• Family member coverage

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.

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

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

• Children’s Equity Act

OPM has implemented 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 in Self Plus One or Self and Family coverage, as appropriate, in the lowest-cost nationwide plan option as determined by OPM
• If you have a Self Only enrollment in a fee-for-service Plan or in an HMO that serves the area where your children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the same option of the same Plan; or
• If you are enrolled in an HMO that does not serve the area where the children live, your employing office will change your enrollment to Self Plus One or Self and Family, as appropriate, in the lowest-cost nationwide plan option as determined by OPM.

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

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

• When benefits and premiums start

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 2021 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 2020 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

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).

• When FEHB coverage ends

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 31st 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 60th 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).

• Upon divorce

If you are divorced from a Federal employee, or annuitant, you may not continue to get benefits under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get information about your coverage choices. You can also visit OPM’s website at www.opm.gov/healthcare-insurance/healthcare/plan-information/. 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.

• Temporary Continuation of Coverage (TCC)

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). The Patient Protection and Affordable Care Act (ACA) did not eliminate TCC or change the TCC rules. 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, if you are a covered dependent child and you turn 26, etc.

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 new kind of tax credit that lowers your monthly premiums. Visit www.HealthCare.gov to compare Plans and see what your premium, deductible, and out-of-pocket costs would be before you make a decision to enroll. Finally, if you qualify for coverage under another group health Plan (such as your spouse’s Plan), you may be able to enroll in that Plan, as long as you apply within 30 days of losing FEHB Program coverage.

• Converting to individual coverage

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

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

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

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed, and your coverage will not be limited due to pre-existing conditions. When you contact us, we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act's Health Insurance Marketplace in your state. For assistance in finding coverage, please contact us at 877-280-2989 or visit our website at www.GlobalHealth.com/fehb.

• Health Insurance Marketplace

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.

Identification cards

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 1-877-280-2989 or write to us at: P.O. Box 2393, Oklahoma City, OK 73101-2393. You may also request replacement cards through our website: www.GlobalHealth.com/fehb.

Where you get covered care

You get care from “Plan providers” and “Plan facilities.” You will only pay deductibles (Standard Option only), copayments, and/or coinsurance.

Plan providers

Plan providers are physicians and other healthcare professionals in our service area that we contract with to provide covered services to our members. We credential Plan providers according to national standards.

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

Plan facilities

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.

What you must do to get covered care

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

Primary care

You may choose a primary care physician by calling Customer Care at 1-877-280-2989 or by going to our website, www.GlobalHealth.com/fehb.

When you enroll, you choose a primary care physician from the GlobalHealth provider network. Each member of the family may choose a different primary care physician, including a pediatrician for children. Your primary care physician can be a family practitioner, internist, pediatrician (for members under the age of 18), or a general practitioner. You have complete freedom of choice of primary care physicians in our network. Your primary care physician will provide most of your healthcare, or give you a referral to see a specialist.

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

Specialty care

Your primary care physician will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must return to the primary care physician after the consultation, unless your primary care physician authorized a certain number of visits without additional referrals. The primary care physician must provide or authorize all follow-up care. Do not go to the specialist for return visits unless your primary care physician gives you a referral. However, you may self-refer for in-network obstetrical/gynecological services and well-woman exams, routine mammograms, behavioral and mental health/chemical dependency counseling services, physical therapy evaluations, routine eye exams or eye wear, chiropractic care, and after hours urgent care visits.

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

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

Your primary care physician will create your treatment plan. The physician may have to get an authorization or approval from us beforehand. If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. If he or she decides to refer you to a specialist, ask if you can see your current specialist.

If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.

• If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.
• If you have a chronic and disabling condition and lose access to your specialist because we:
  • terminate our contract with your specialist for other than cause;
  • drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Program Plan; or,
  • reduce our service area and you enroll in another FEHB Plan;

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

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

Hospital care

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

If you are hospitalized when your enrollment begins

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 Care Department immediately at 877-280-2989. If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

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

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

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

You need prior Plan approval for certain services

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

You must get prior approval for certain services. Failure to do so may result in noncoverage of the service.

Other services

Your primary care physician will obtain prior authorization for any specialty care you may need. GlobalHealth must preauthorize all inpatient and outpatient services at a contracting facility, except stays in connection with childbirth, emergency room care, after hours urgent care, obstetrical/gynecological services and well-woman exams, routine mammograms, behavioral health/chemical dependency counseling services, routine eye exams or eye wear, chiropractic care, and physical therapy evaluations. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice.

You must obtain prior authorization for:

• Specialist visits, except those listed above
• Non-routine lab, X-ray, and other diagnostic tests
• Specialized scans, imaging, and diagnostic exams
• Preventive care
• Abdominal aortic aneurysm screening
• BRCA test
• Lung cancer screening
• Breastfeeding supplies and equipment
• Voluntary sterilization
• Infertility treatment
• Chemotherapy, respiratory and inhalation therapy, radiation, dialysis, infusion therapy, growth hormone therapy, hyperbaric oxygen therapy
• Cardiac rehabilitation
• Pulmonary rehabilitation
• Applied behavioral analysis
• Physical therapy, occupational therapy, and speech therapy
• Hearing aids and implanted hearing-related devices
• Foot care
• Orthopedic and prosthetic devices
• Durable medical equipment
• Diabetic supplies
• Home health services
• All surgical procedures provided in specialists' offices
• Organ/tissue transplants
• Inpatient hospital admissions, except for childbirth
• Outpatient hospital or other covered facility visits
• Extended care benefits/Skilled nursing care facility benefits
• Hospice care
• Non-emergency ambulance services
• Certain prescription drugs
• Dental anesthesia

First, your physician, your hospital, you, or your representative, must call us at 877-280-2989 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.

Non-urgent care claims

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.

Urgent care claims

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

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

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

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us as 1-877-280-2989. 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 1-877-280-2989. 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).

Concurrent care claims

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.

The Federal Flexible Spending Account Program - FSAFEDS

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

Emergency inpatient admission

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

Maternity care

GlobalHealth will only cover the costs of your care when provided by your primary care physician, or a network provider specializing in obstetrics or gynecological care. You will be responsible for the cost of your care if you obtain services from an out-of-network provider unless it is an urgent or emergency occurrence or situation. For a list of network healthcare professionals who specialize in obstetrics and gynecology, refer to the online provider directory or contact Customer Care.

You do not need preauthorization of a maternity admission for 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 authorization of additional days. Further, if your baby stays after your are discharged, then your physician or the hospital must contact us for authorization of additional days for your baby.

If your treatment needs to be extended

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

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

You must obtain an authorized referral prior to a scheduled hospital stay or outpatient surgery. Referrals are not required for emergency room visits or stays in connection with childbirth. You must go to a network facility for childbirth unless you are having contractions and there is inadequate time to effect a transfer to another hospital before delivery or the transfer may pose a threat to the health or safety of you or your unborn child. If you choose to obtain services, other than emergencies, from an out-of-network provider, you are financially responsible.

Circumstances beyond our control  

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

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

If 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.

To reconsider a non-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. 

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

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

2.  Ask you or your provider for more information.

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

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

3.  Write to you and maintain our denial.

To reconsider an urgent care claim

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

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

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

Cost-sharing

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.

Copayments

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

Example: When you see your primary care physician, you pay a copayment of $0 per office visit, and when you go in the hospital, you pay $250 per day up to a maximum of $750 per admission under our High Option.

Deductible

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

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

• We do not have a deductible under our High Option.

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

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

Coinsurance

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 under our High Option.

Differences between our Plan allowance and the bill

Plan allowance is the allowed amount we will pay for services rendered based on contractual rates with our providers.

GlobalHealth offers set copayments on all services except durable medical equipment, orthotics and prosthetics that are not surgically implanted, hearing aids, and specialty drugs which have coinsurance. The copayments do not vary depending on the allowed amount.

Balance billing occurs when a provider bills you the difference between its billed charge and the total amount the provider received from your cost-share and our usual and customary reimbursement for approved covered services. In-network providers may not balance bill you. Out-of-network providers may balance bill you and you will be responsible for the difference between our payment and the provider's billed amount.

Your catastrophic protection out-of-pocket maximum

High Option: After your copayments and coinsurance total $5,000 for Self Only, or $7,000 for a Self Plus One or Self and Family enrollment in any calendar year, you do not have to pay any more for covered services. The maximum annual limitation on cost sharing listed under Self Only of $5,000 applies to each individual, regardless of whether the individual is enrolled in Self Only, Self Plus One, or Self and Family.

Standard Option: After your deductible, copayments, and coinsurance total $6,500 for Self Only, or $7,500 for a Self Plus One or Self and Family enrollment in any calendar year, you do not have to pay any more for covered services. The maximum annual limitation on cost-sharing listed under Self Only of $6,500 applies to each individual, regardless of whether the individual is enrollment in Self Only, Self Plus One, or Self and Family.

Example Scenario: Your Plan has a $5,000 Self Only maximum out-of-pocket limit and a $7,000 Self Plus One or Self and Family maximum out-of-pocket limit. If you or one of your eligible family members has out-of-pocket qualified medical expenses of $5,000 or more for the calendar year, any remaining qualified medical expenses for that individual will be covered fully by your health Plan. With a Self Plus One or Self and Family enrollment out-of-pocket of $7,000, a second family member, or an aggregate of other eligible family members, will continue to accrue out-of-pocket qualified medical expenses up to a maximum of $2,000 for the calendar year before their qualified medical expenses will begin to be covered in full.

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

• 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 of your copayments and coinsurance to ensure the Plan's calculation of your out-of-pocket maximum is reflected accurately.

Carryover

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.

When Government facilities bill us

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.

Prior Authorization

Physicians are required to obtain prior authorization for certain medications, including compound drugs. This promotes appropriate, cost-effective use. Any corresponding supplies or equipment also require prior authorization. We may not cover the drug, supply, or equipment without prior authorization.

Step Therapy

Step therapy requires one or more prerequisite, clinically equivalent drugs to be tried before a step therapy drug will be covered.

Quantity Limits

There are limits to the amount of certain medications that you may receive. These drugs, if taken inappropriately for too long a time period, could be unsafe and cause adverse effects.

Requesting a Standard 
Exception

You can request GlobalHealth to waive coverage restrictions and limits. Call 1-877-280-2989. Generally, we will only approve your request for an exception if:

• The alternative drug is included on the Plan's formulary;
• The drug without additional utilization restrictions would not be as effective in treating your condition; and
• It would cause you to have adverse medical effects.

We will not approve a request to lower your cost-share for a drug.

In the case of a request to cover a non-formulary drug, the physician must include:

• A justification supporting the need for the non-formulary drug to treat your condition; and
• A statement that all covered formulary drugs on any tier will be or have been ineffective, would not be as effective as the non-formulary drug, or would have adverse effects.

You, your designee, or your physician should contact us for instructions on obtaining a utilization restriction exception. Your physician may have to submit a prior authorization request form with supporting information. A decision is made within 72 hours of receiving your request and sufficient information to begin the review.

If granted, the exception will be for the duration of the prescription, including refills. You may submit your request by calling 1-877-280-2989.

Requesting an Expedited Exception

You, your designee, or your prescribing physician may request an expedited exceptions process, when:

• You are suffering from a health condition that may seriously jeopardize your life, health, or ability to regain maximum function, or
• You are undergoing a current course of treatment using a non-formulary drug.

We will provide a decision to you, your designee, or the prescribing physician within 24 hours after receiving the request and sufficient information to begin the review. If granted, the exception will be for the duration of the prescription, including refills.

You may submit your request by calling 877-280-2989.

Flexible benefits option

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).

24 hour nurse and information line

For any of your health concerns, 24 hours a day, 7 days a week, you may call and talk with a registered nurse who will discuss treatment options and answer your health questions. Call 1-877-280-2989 anytime.

Services for deaf and hearing impaired

Health improvement programs

• Nutritional Training for Diabetes
• Diabetes preventive program
• Health resources - Address other diseases, medications, weight programs, nutrition

Contact Customer Care at 1-877-280-2989.

Tobacco Cessation

Cessation attempts: We cover 2 tobacco cessation attempts per calendar year. One attempt is considered:

• Four tobacco cessation counseling sessions; and
• All FDA-approved tobacco cessation drugs (including both prescription and over-the-counter).

Prior authorization is not required. You pay more for additional treatment or non-generic drugs.

Studies show that the most effective method to stop smoking involves:

• Counseling;
• Social support; and
• The use of cessation medication.

Counseling and medication are both effective for treating tobacco dependence, and using them together is more effective than using either one alone.

• Tobacco products include:
• Candy-like products that contain tobacco
• Cigarettes
• Cigars
• Smokeless tobacco
• Smoking tobacco
• Snuff
• Tobacco Cessation

Counseling:

• You may attend individual, group, or phone counseling sessions of at least 10 minutes each through your PCP or behavioral health provider.
• You may also call the Oklahoma Tobacco Helpline at 1-800-QUIT-NOW (1-800-784-8669). You will talk to a trained cessation expert. He or she will tailor a plan for your specific needs.

Prescriptions:

• Smoking cessation products are limited to 2 full 90-day courses of any FDA-approved tobacco cessation product per calendar year, if prescribed by your PCP or behavioral health provider. This benefit is available to you as well as your enrolled dependents who are at least 18 years old.
• The covered drugs include: Chantix™ (varenicline), Nicotrol® Inhaler (nicotine), Nicotrol® Nasal Spray (nicotine), and bupropion SR 150 mg (generic for Zyban®).
  • However, if your provider recommends another drug based on determination of medical necessity for you, we will cover that drug at no cost-share. See "Exception Requests" in Section 5(f).
• We also cover FDA-approved over-the-counter products (such as nicotine patches, gum, inhalers, nasal sprays, and lozenges) with a prescription written by your physician.
• Not all products that may be used for tobacco cessation are included. For example, we do not cover electronic cigarettes available over-the-counter.

Enroll: You can enroll by contacting Customer Care or on our website.

Translation services

Our health Plan offers over 150 languages from professional, certified medical interpreters. Call Customer Care for help or 711 (TTY). Spanish (Español): Para obtener asistencia en Español llame al 1-877-280-2989.

Medical Therapy Management Program

If you are taking multiple medications for chronic conditions, you can receive support from our Medication Therapy Management Program. You may self-refer or be referred by your provider or a GlobalHealth staff member. You receive personalized service from registered pharmacists and staff. The goal of the program is:

• To slow disease progression by supporting drug compliance.
• To help eliminate duplicate drug therapies.
• To reduce potential for negative drug interactions and side effects.
• To optimize your benefits by advising of the lowest cost alternatives.

We conduct drug use reviews to help make sure that you are getting safe and appropriate care. These reviews are especially important if you have more than one provider who prescribes drugs for you.

During these reviews, we look for potential problems such as:

• Possible drug errors;
• Drugs that may not be necessary because you are taking another drug to treat the same medical condition;
• Drugs that may not be safe or appropriate because of your age or gender;
• Certain combinations of drugs that could harm you if taken at the same time;
• Prescriptions written for drugs that have ingredients you are allergic to; and
• Possible errors in the amount (dosage) of a drug you are taking.

If we see a possible problem in your use of drugs, we will work with your provider to correct the problem.

This program is voluntary and at no cost to you. You can contact Customer Care if you would like to participate in the program. If you decide to opt out at any time, please contact Customer Care and we will withdraw you from the program.

Quality Improvement Program

You may request information regarding our Quality Improvement Program and work plan by contacting Customer Care. Ask to be connected to the Quality Department or email quality@globalhealth.com.

Care management programs

If you have a chronic disease or complex healthcare needs, you have three types of care management programs that provide patient education and clinical support.

Proactive Outreach: For members with complex healthcare needs, we provide you with the services of a professional case manager to assess your needs and when appropriate, coordinate, evaluate, and monitor your care.

Diabetes Prevention Program: We provide an intensive behavioral and lifestyle change program for members with high blood glucose readings but have not been diagnosed with diabetes.

Prenatal Outreach Program: Our clinical staff reach out to pregnant members to encourage using prenatal benefits and follow up after the birth of the baby to help you have a healthy pregnancy and healthy baby.

If you have any questions regarding these programs, or would like to self-refer, please contact Customer Care.

Surveys

Your Health: Each year, we will send you a health appraisal that asks questions about your current health. Your answers help us know how to best serve you and your healthcare needs. The information you give us will remain confidential as required by law. It will not be used against you in any way or prevent you from obtaining services and treatment.

Your Satisfaction: We distribute member satisfaction surveys to see how well you believe your doctors and health Plan are serving your needs. They may include:

• New Member Survey;
• Customer Satisfaction Study; and
• Consumer Assessment of Healthcare Provides and Systems (CAHPS®).

GlobalHealth performs an audit that is approved by the National Committee for Quality Assurance (NCQA) called HEDIS® (Healthcare Effectiveness Data Information Systems). It measures the quality of preventive care our network providers deliver. One part of this audit is the CAHPS® survey. It is very important that you complete and return it. Your answers will help us improve service.

Technology assessment process

GlobalHealth has a technology assessment and guideline review process. It is designed to review requests for coverage of newly available devices, procedures, or treatments that are not considered established benefits.

A physician-directed committee reviews all requests for new technology. This includes:

• New technology; or
• New application of existing technology.

The committee reviews medical and behavioral healthcare procedures, drugs, and devices using scientific medical evidence. An appropriate regulatory agency, such as the U.S. Food and Drug Administration (FDA), must have approved the new device, procedure, or treatment before it will be considered.

Before approving coverage, GlobalHealth requires documented evidence to ensure the efficacy and safety of the new technology. The new technology must:

• Improve the net health outcome of the member;
• Be as beneficial as established alternatives;
• Be available outside the investigational setting;
• Significantly improve the quality of life of the member; and
• Clearly demonstrate safe medical care to the member.

Contact Customer Care.

Drug cost calculator

https://www.globalhealth.magellanrx.com/

MyGlobal™ Member Portal

You may register for a secure member portal called MyGlobal™. Through MyGlobal™, you can monitor claims, referrals, and change your PCP in addition to other features that help you manage your account.

Value Max Program

Value Max program is available to GlobalHealth Members at no cost. This program is designed to identify the highest copayment assistance available for eligible drugs, typically resulting in a lower copayment for you. To benefit from this program, you must fill eligible prescriptions through Magellan Rx pharmacy, a mail-order pharmacy. You can find the current list of eligible drugs on our website at https://globalhealth.com/pharmacy/value-max-program/.
If you receive a drug on the Value Max drug list, you will be automatically enrolled in the Value Max program. You may disenroll from the program at any time. If you do not already receive your prescriptions from Magellan Rx Pharmacy, you must disenroll from the program to continue to receive your prescriptions at your local pharmacy.
If you have any questions about the Value Max program, please contact Magellan at 1-800-424-1789 (toll-free) or GlobalHealth at 1-877-280-5600 (toll-free). You can also review the Value Max Program Frequently Asked Questions on our website at https://globalhealth.com/pharmacy/value-max-program/.

How to enroll:
Each of these programs is a team effort and that team includes you, your caregiver (if you wish), your doctors, and our GlobalHealth team members.
We will automatically enroll you in these programs, except the Medication Therapy Management and Tobacco Cessation Programs, if you meet the criteria. You, your caregiver, discharge planner, or doctor can ask us to enroll you in any of these programs. Participation is voluntary, confidential, and available at no cost to you. You may opt out at any time.
Call us if you have any questions.

Medical and hospital benefits  

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 1-877-280-2989, or at our email at FederalAnswers@globalhealth.com.

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

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

GlobalHealth
P.O. Box 2328
Oklahoma City, OK 73101-2328

1-877-280-2989 (toll-free)

711 (TTY)

Mental health and substance abuse benefits

Submit your claims to:

Beacon Health Claims
P.O. Box 1850
Hicksville, NY 11802-1850

1-888-434-9201

1-866-835-2755 (TTY)

Prescription drugs

Submit your claims to: 

Magellan Health Services Claims Department
11013 W Broad Street, Suite #500
Glen Allen, VA 23060

1-800-424-1789 (toll-free)

Deadline for filing your claim

Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you received the service, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible.

Post-service claims procedures

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.

Authorized Representative

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

Notice Requirements

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

1

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 GlobalHealth, P.O. Box 2393, Oklahoma City, OK 73101-2393; and

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

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

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

We will provide you, free of charge and in a timely manner, with any new or additional evidence considered, relied upon, or generated by us or at our direction in connection with your claim and any new rationale for our claim decision. We will provide you with this information sufficiently in advance of the date that we are required to provide you 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.

2

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.

3

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.

4

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

If you do not agree with OPM's decision, your only recourse is to 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.

When you have other health coverage

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

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

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

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

• TRICARE and CHAMPVA

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 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.

• Workers’ Compensation

We do not cover services that:

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

Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care.

• Medicaid

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 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.

When other Government agencies are responsible for your care

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

When others are responsible for injuries

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.

When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) coverage

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.

Clinical trials

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 covers some of these costs, providing the Plan determines the services are medically necessary. We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.
• Research costs - costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes. These costs are generally covered by the clinical trials. This Plan does not cover these costs.

When you have Medicare

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 (Part A or Part B)

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

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

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

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

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

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 1-877-280-2989 or see our website at www.GlobalHealth.com/fehb.

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

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

High Option

Benefit Description: Deductible
You pay without Medicare: $0 
You pay with Medicare Parts A and B:$0

Benefit Description: Out of Pocket Maximum
You pay without Medicare: High Option: $5,000 self only/$7,000 Self Plus One or Self and Family
You pay with Medicare Parts A and B:$5,000 self only/$7,000 Self Plus One or Self and Family

Benefit Description: Part B Premium Reimbursement Offered
You pay without Medicare: N/A
You pay with Medicare Parts A and B: None

Benefit Description: Primary Care Physician
You pay without Medicare: $0
You pay with Medicare Parts A and B:$0

Benefit Description: Specialist
You pay without Medicare: $35 copayment
You pay with Medicare Parts A and B:$35 copayment

Benefit Description: In-Patient Hospital
You pay without Medicare: $250 per admission/maternity; $250 copayment per day up to $750 copayment per admission
You pay with Medicare Parts A and B:$250 per admission/maternity; $250 copayment per day up to $750 copayment per admission

Benefit Description: Out-Patient Hospital
You pay without Medicare:  $250 copayment/preferred facility; $750 copayment/non-preferred facility
You pay with Medicare Parts A and B:$250 per admission/maternity;$250 copayment per day up to $750 copayment/non-preferred facility
Benefit Description: Incentives Offered
You pay without Medicare: N/A
You pay with Medicare Parts A and B: None

Standard Option

Benefit Description: Deductible
You pay without Medicare: $500 Self Only/$1,000 Self Plus One or Self and Family
You pay with Medicare Parts A and B: $500 Self Only/$1,000 Self Plus One or Self and Family

Benefit Description: Out of Pocket Maximum
You pay without Medicare: High Option: $6,500 self only/$7,500 Self Plus One or Self and Family
You pay with Medicare Parts A and B:$6,500 self only/$7,500 Self Plus One or Self and Family

Benefit Description: Part B Premium Reimbursement Offered
You pay without Medicare: N/A
You pay with Medicare Parts A and B: None

Benefit Description: Primary Care Physician
You pay without Medicare: $0
You pay with Medicare Parts A and B:$0

Benefit Description: Specialist
You pay without Medicare: $50 copayment
You pay with Medicare Parts A and B:$50 copayment

Benefit Description: In-Patient Hospital
You pay without Medicare: $500 copayment per admission/maternity; $750 copayment per day up to $1,500 copayment per admission
You pay with Medicare Parts A and B:$500 copayment per admission/maternity; $750 copayment per day up to $1,500 copayment per admission

Benefit Description: Out-Patient Hospital
You pay without Medicare: $500 copayment/preferred facility;$1,000 copayment/non-preferred facility
You pay with Medicare Parts A and B:$500 copayment/preferred facility;$1,000 copayment/non-preferred facility

Benefit Description: Incentives Offered
You pay without Medicare: N/A
You pay with Medicare Parts A and B: None

• Tell us about your Medicare coverage

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

• Medicare Advantage (Part C)

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage Plan. These are private healthcare choices (like HMOs and regional PPOs) in some areas of the country.

To learn more about Medicare Advantage Plans, contact Medicare at 800-MEDICARE (1-800-633-4227), (TTY 1-877-486-2048) or at www.medicare.gov.

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

This Plan and our Medicare Advantage Plan: You may enroll in our Medicare Advantage Plan and also remain enrolled in our FEHB Plan. In this case, some coordination of benefits will apply. For more information about our Medicare Advantage Plans, please call 1-844-280-5555.

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 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.

• Medicare prescription drug coverage (Part D)

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

Calendar year

January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on December 31 of the same year.

Clinical trials cost categories

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

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

Coinsurance

See Section 4, page (Applies to printed brochure only).

Copayment

See section 4, page (Applies to printed brochure only).

Cost-sharing

See section 4, page (Applies to printed brochure only).

Custodial care

Care which is primarily for the purpose of assisting in the activities of daily living or in meeting personal rather than medical needs, which is not specific therapy for an illness or injury and is not skilled care.

Deductible

See section 4, page (Applies to printed brochure only).

Group health coverage

Health benefits provided to a group of people, usually through an employer, by a single policy or contract in exchange for a premium.

Services we determine are appropriate for the treatment or diagnosis of an illness or injury.

Non-preferred facilities

A facility which has a contract with GlobalHealth to provide services to you at a discount. You will pay the higher cost-share when you choose these facilities instead of a preferred facility.

Plan allowance

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 based on contractual rates with our providers.   

GlobalHealth offers set copayments on all services except durable medical equipment, orthotics, prosthetics that are not surgically implanted, hearing aids, and specialty drugs which have coinsurance. The copayments do not vary depending on the allowed amount.

Post-service claims

Any claims that are not pre-service claims. In other words, post-service claims are those claims where treatment has been performed and the claims have been sent to us in order to apply for benefits.

Preferred facility

A facility which has a contract with GlobalHealth to provide services to you at a discount. You will pay the lower cost-share when you choose these facilities instead of a non-preferred facility.

Reimbursement

A carrier's pursuit of a recovery if a covered individual has suffered an illness or injury and has received, in connection with that illness or injury, a payment from any party that may be liable, any applicable insurance policy, or workers' compensation program or insurance policy, and the terms of the carrier's health benefits Plan require the covered individual, as a result of such payment, to reimburse the carrier out of the payment to the extent of the benefits initially paid or provided. The right of reimbursement is cumulative with and not exclusive of the right of subrogation.

Urgent care claims

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 evaluate 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 our Customer Care Department at 877-280-2989. 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.

Medical services provided by physicians: Diagnostic and treatment services provided in the office

Office visit copay: Nothing for primary care; $35 specialist

(Applies to printed brochure only)

Services provided by a hospital:

• Inpatient
• Outpatient

Inpatient: $250 copay per day up to a maximum of $750 copay per admission; Outpatient: $250 copay in preferred facility; $750 copay in non-preferred facility

(Applies to printed brochure only)

Emergency benefits:

• In-area
• Out-of-area

Nothing per PCP visit; $35 copay per specialist visit; $25 copay per urgent care visit; $250 copay per emergency room visit

(Applies to printed brochure only)

Mental health and substance use disorder treatment:

Office visit: Nothing; Inpatient: $250 copay per day with a maximum of $750 copay per admission; Outpatient facility: $200 copay per admission

(Applies to printed brochure only)

Prescription drugs:

• Retail and specialty pharmacy - 30-day supply

Tier One – Covered generic drugs - $4/$12 copay at in-network pharmacy
Tier Two – Covered preferred brand name drugs - $50 copay at in-network pharmacy
Tier Three – Covered non-preferred drugs - $80 copay at in-network pharmacy
Tier Four – Covered preferred specialty drugs - 10% coinsurance with a maximum of $150 at in-network pharmacy - oral chemotherapy drugs have a maximum of $100
Tier Five – Covered non-preferred specialty drugs - 10% coinsurance with a maximum of $250 at in-network pharmacy - oral chemotherapy drugs have a maximum of $100

(Applies to printed brochure only)

Mail order and extended supply - 90-day supply

Tier One – Covered generic drugs - $8/24 copay at in-network pharmacy
Tier Two – Covered preferred brand name drugs - $125 copay at in-network pharmacy
Tier Three – Covered non-preferred drugs - $240 copay at in-network pharmacy

68

Vision care:

One eye refraction annually - $40 copay

(Applies to printed brochure only)

Protection against catastrophic costs (out-of-pocket maximum):

Nothing after $5,000/Self Only or $7,000/Self Plus One or $7,000/Self and Family enrollment per year. Some costs do not count toward this protection.

(Applies to printed brochure only)

Medical services provided by physicians:

Diagnostic and treatment services provided in the office

Office visit copay: Nothing for primary care; $50 specialist

(Applies to printed brochure only)

Services provided by a hospital:

• Inpatient
• Outpatient

*Inpatient: $750 copay per day up to a maximum of $1,500 copay per admission;
*Outpatient: $500 copay in a preferred facility; $1,000 copay in a non-preferred facility

(Applies to printed brochure only)

Emergency benefits:

• In-area
• Out-of-area

Nothing per PCP visit; $50 copay per specialist visit; $45 copay per urgent care visit; *$300 copay per emergency room visit

(Applies to printed brochure only)

Mental health and substance use disorder treatment:

Office visit: Nothing; *Inpatient: $750 copay per day up to a maximum of $1,500 copay per admission; *Outpatient facility: $300 copay per admission

(Applies to printed brochure only)

Prescription drugs:

• Retail and specialty pharmacy - 30-day supply

Tier One – Covered generic drugs - $6/$15 copayment at in-network pharmacy
Tier Two – Covered preferred brand name drugs - $85 copayment at in-network pharmacy
Tier Three – Covered non-preferred drugs - $120 copayment at in-network pharmacy (oral chemotherapy drugs have a maximum of $100)
Tier Four – Covered preferred specialty drugs - 10% coinsurance with a maximum of $400 at in-network pharmacy (oral chemotherapy drugs have a maximum of $100)
Tier Five – Covered non-preferred specialty drugs - 10% coinsurance with a maximum of $600 at in-network pharmacy (oral chemotherapy drugs have a maximum of $100)

(Applies to printed brochure only)

• Mail order and extended supply - 90-day supply

Tier One – Covered generic drugs - $12/30 copayment at in-network pharmacy
Tier Two – Covered preferred brand name drugs - $170 copayment at in-network pharmacy
Tier Three – Covered non-preferred drugs - $240 copayment at in-network pharmacy

68

Vision care:

One eye refraction annually - $50 copay

(Applies to printed brochure only)

Protection against catastrophic costs (out-of-pocket maximum):

Nothing after $6,500/Self Only or $7,500/Self Plus One or $7,500/Self and Family enrollment per year. Some costs do not count toward this protection.

(Applies to printed brochure only)