• No pre-existing condition limitation

• 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-insurancefor 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;
• When your enrollment ends; and
• When the next Open Season for enrollment begins.

We don’t determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office.

For information on your premium deductions, 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, 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.

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

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

If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for FEHB coverage, you must continue 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-packet 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 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 situation 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 Temporary Continuation coverage (TCC), or a conversion policy (a non-FEHB individual policy.)

• Upon divorce

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

You may not elect TCC if you are fired from your Federal job or Tribal 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 FEHBP coverage.

The Affordable Care Act Health Insurance Marketplace is not available in our service area. 

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

If you leave Federal or Tribal service, your employing office will notify you of your right to convert. You must apply in writing to us 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 apply in writing to us 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 671-477-9808 or visit our website at www.calvos.net.

• 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.

The Affordable Care Act Health Insurance Marketplace is not available in our service area.

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 (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 671-477-9808 or write to us at      P.O. Box FJ, Hagatna, Guam 96932. 

Where you get covered care

You get care from “Plan providers” and “Plan facilities.” You will only pay copayments, deductibles, and/or coinsurance. How much you pay depends on whether you use a Plan/Participating provider and facility or non-network provider or facility. If you use your out-of-network program, you can get care from non-Plan providers but it will cost you more.

We look at some or all of the following criteria to determine if a provider is recognized and approved by us:

• Is the provider accredited by a recognized accrediting agency?
• is the provider appropriately licensed?
• Is the provider certified by the proper government authority?
• Are the services rendered within the lawful scope of the provider's respective licensure, certification, and/or accreditation?

Medicare beneficiaries may only receive covered services at a Plan participating Medicare-contracted facility in Guam, Saipan, Hawaii, and the Continental United States. Medicare eligible care and services which are rendered at a facility which is not a Medicare contracted facility, or which is rendered by a physician who is not a Medicare contracted physician will not be covered.

Out-of-Network/Non-Plan providers

Out-of-Network/Non-Plan providers are physician and other health care professionals who are not under contract with this Plan. You can get care from Out-of-Network/non-Plan providers, but it will likely cost you more.

Certain services always require prior approval, regardless of whether they are rendered in-network or out-of-network (see Section 3 You need prior Plan approval for certain services). If you self-refer to a provider and/or facility for services which require prior authorization, those services will not be covered.

In-Network/Plan facilities

In-Network/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.

In-network/Plan providers

In-Network/Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential In-Network/Plan providers according to national standards.

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

Your primary care physician can be a family practitioner, internist, obstetrician/gynecologist, or pediatrician for children under 18 years of age . Your primary care physician will provide most of your health care, 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.

Specialty care

Your primary care physician, and in some situations, a specialist, will refer you to a specialist for needed care. When you receive a referral from your primary care physician, you must return to the primary care physician after the consultation, unless your primary care physician authorized a certain number of visits without additional referrals. The primary care physician must provide or authorize all follow-up care. Do not go to the specialist for return visits unless your primary care physician gives you a referral. However, you may see an OB/GYN within our provider network without a referral.

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

• If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. Your primary care physician will use our criteria when creating your treatment plan (the physician may have to get an authorization or approval beforehand).
• If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you need. 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; or
  • 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.

We pay for covered services form 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 671-477-9808. If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

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

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

You need prior Plan approval for certain services

Your primary care physician arranges most referrals to specialists and inpatient hospitalization and sends the referrals to the Plan for approval. The pre-service claim approval process applies to care shown under Other Services.

The pre-service claim approval process for services is detailed in this Section. A pre-service claim is any claim, in whole or in part, that requires approval from us in advance of obtaining medical care or services. In other words, a pre-service claim for benefits (1) requires pre certification or prior approval and (2) will result in a denial or reduction of benefits if you do not obtain precertification or prior approval. 

Inpatient hospital admission

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.

Other services

Your primary care physician has authority to refer you for most services. For certain services, however, your physician or specialist must obtain prior approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice. You must obtain prior authorization for:

• Allergy testing and allergy serum
• All diagnostic and surgical procedures performed in a surgical facility
• Audiological exams
• Bariatric surgery
• Bone density studies
• Certain drugs listed in our Prescription Drug Formulary (see Section 5(f))
• Chemotherapy Agents
• CT scans
• Durable medical equipment
• Genetic Testing
• Growth Hormone Therapy (GHT)
• Home Health services
• Hospitalization
• Infertility Services and Infertility Drugs
• MRIs
• Non-routine mammograms
• Off-island services (except for preventive service) and consultations
• Oncology consultations
• Orthopedic, Prosthetic, and Implantable devices
• Out-of-area hospitalization
• Plastic/reconstructive consultation and procedures
• Therapy treatment plans- occupational therapy, physical therapy, speech therapy
• Podiatry consultations and procedures
• Sleep studies
• Specialty care procedures
• Transplants
• Ultrasounds, sonograms including echocardiogram
• Other procedures including colonsocopy and endoscopy (except for preventive services)

Emergency services do not require pre certification. However, you or your family member must notify the Plan within 48 hours, or as soon as is reasonably possible, in order for the services to be covered.

For any out-of-service area primary and specialty care services rendered by in-network or out-of-network providers that was not prior authorized, you or your representative must contact us within two business days following the date of service or as soon as is reasonably possible. Failure to notify the Plan may result in denial of benefits.

The list of services requiring prior approval may change periodically. To ensure your treatment or procedure is covered, call us at 671-477-9808.

How to request precertification for an admission or get prior authorization for Other services

First, your physician, your hospital, or your representative, must call us at 671-477-9808 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 any hospital admission outside of our service area and/or at non-participating providers, that was not prior authorized, you, your representative, the physician, or the hospital must contact us within two business days following the day of the admission or as soon as is reasonably possible, even if you have been discharged from the hospital. Failure to notify the Plan may result in a denial of benefits.

Non-urgent care claims

For non-urgent care claims, we will then 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 and urgent care claims by applying the judgement 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) 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 671-477-9808. You may also call OPM's Health Insurance 3 at 202-606-0737 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, call us at 671-477-9808. 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 fiLE 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 contact us within two business days following the day of the emergency admission, even if you have been discharged from the hospital.

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, 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

Failure to obtain prior approval may result in a denial of benefits if the services or devices do not meet Calvo's SelectCare payment determination criteria.

Circumstances beyond our control

Under certain 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 disagree with our pre-service claim decision

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

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

To file and appeal with OPM

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.

Coinsurance is the percentage of our allowance that you must pay for your care. 

Example: In our Plan, you pay 30% of eligible charges and any difference between eligible charges and billed charges for out-of-network services.

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 $15 per office visit, and when you go in the hospital, you pay $200 per admission.

Deductible

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

• In-network - No deductible.
• Out-of-network - The calendar year deductible is $500 per person under the High and 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 out-of-network deductible for your enrollment reach $500 under High and 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 out-of-network deductible for your enrollment reach $1,000 under High and Standard Option. Under a Self and Family enrollment, the deductible is considered satisfied and benefits are payable for you and one other eligible family member when the combined covered expenses applied to the calendar year out-of-network deductible for your enrollment reach $1,500 under High and Standard Option.

A Calvo's SelectCare deductible claim form should be filled out immediately and kept safe to ensure accurate and complete information on all doctors, lab or pharmacy visits. It is your responsibility to track and submit deductible expenses (e.g. encounter tickets, invoices, receipts) and the required documentation. All claims forms should be submitted to the Calvo's SelectCare Customer Service Department.

Eligible Charges

For most medical services, we calculate our payment and your copayment/coinsurance based on eligible charges. The eligible charge is the lower of either the provider's actual charge or the amount we established as the maximum allowable fee.

Non-plan providers are not under contract to limit their charges to our eligible charges. You are responsible for any charges in excess of eligible charges.

Your catastrophic protection out-of-pocket maximum

High Option: After your medical copayments and coinsurance for in-network covered services total $2,000 for self only or $2,000 per person for Self Plus One or $6,000 per Self and Family enrollment in any calendar year, you do not have to pay any more for in-network covered medical services. However, please note that the Plan does not have out-of-pocket maximums for any out-of-network services.

Standard Option: After your medical copayments and coinsurance for in-network covered services total $3,000 for self only or $3,000 per person for Self Plus One or $8,000 per Self and Family enrollment in any calendar year, you do not have to pay any more for in-network covered medical services. However, please note that the Plan does not have out-of-pocket maximums for any out-of-network services.

There is a separate out-of-pocket maximum for prescription drugs. After your prescription copayments and coinsurance at in-network pharmacies total $2,000 for Self only or $2,000 per person for Self Plus One or $4,000 per family enrollment in any calendar year, you do not have to pay any more for covered prescription drugs at in-network pharmacies.

Be sure to keep accurate records of your copayments/coinsurance. We will also keep records of your in-network coinsurance/copayments and track your in-network catastrophic protection maximums.

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.

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

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 a stated time period (unless circumstances change). You may request and 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).

The airfare benefit applies when a member has a catastrophic illness which requires Qualified Medical Treatment or Procedures that are not available on Guam.This benefit cannot be used in conjunction with the Travel Benefit.

When approved in advance by Calvo’s SelectCare, the Airfare Benefit specifically covers the economy round-trip airfare for the member, a companion, and a medical attendant, if required. If the member qualifies for the Airfare Benefit, Calvo’s SelectCare will only pay or reimburse the member the actual cost or the lowest medical economy rate, whichever is lower. Airfare penalties are excluded from this benefit.

The Plan will only pay charges under this benefit if the proposed services are performed at direct-contracted Network Providers AND if the proposed services meet one of the following Qualifying Conditions / Procedures: Open Heart Surgery, Oncology Surgery, Aneurysmectomy, Pneuctomy, Intra-cranial Surgery, Acute Leukemia, Gamma Knife Surgery,  NICU level III care.

FEHB Members covered by Medicare: Medicare beneficiaries may only receive services at a Plan participating Medicare-contracted facility in Guam, Saipan, Hawaii, and the Continental United States. Medicare eligible care and services which are rendered at a facility which is not a Medicare contracted facility, or which is rendered by a physician who is not a Medicare contracted physician will not be covered. FEHB members with Medicare as their primary payer are only eligible for the Airfare Benefit to direct-contracted Network providers in the Continental United States.

For more information about this benefit, contact Calvo's SelectCare Customer service at (671) 477-9808.

Travel Benefit

For pre-authorized, elective, in-patient or out-patient 

• Surgical procedures
• High-level specialist consultations (including but not limited to cardiology, gastroenterology, hepatology, hematology, nephrology, neurology, oncology, orthopedic services, pulmonology, etc.)
• High-level radiology diagnostic services (including but not limited to PET scans, MRIs, etc.)

at participating providers in the Philippines and Taiwan, (excluding emergencies, preventive services, home health, hospice or maternity-related services), Calvo's SelectCare offers a travel benefit of up to $500 per member (one travel benefit per member per year) on a reimbursement basis and to be applied toward the cost of round-trip airfare between Guam and Manila, Philippines or between Guam and Taipei, Taiwan, or ground transportation between airport and the hospital or lodging in the Philippines  or Taiwan during the same time period as the procedure / consultation / diagnostic service. This benefit cannot be used in conjunction with the Airfare Benefit. Benefit is limited to one (1) travel benefit per member per year.

Some services may not be eligible for the travel benefit reimbursement.

 In order for the procedure, service or specialist consultation to be prior authorized as a covered benefit and eligible for the travel benefit, the following are required:

• Referrals and medical notes from primary care providers (or specialists, if applicable) to determine medical necessity
• Must meet medical necessity criteria
• Must be a covered benefit and
• Approval request for the procedure/consultation/diagnostic service must be submitted to and approved by Plan prior to departure to the Philippines or Taiwan

Upon return from the Philippines or Taiwan, members must submit to Calvo's SelectCare the following documents for reimbursement:

• Completed Calvo's SelectCare reimbursement form
• Pre-authorization document from the Plan
• Letter of authorization from the Plan's Philippine offices or Guam office , and
• Receipts for airfare or lodging or transportation which clearly detail dates of travel / stay / transfers, amounts paid, and names of persons who made payments

Members are responsible for making their travel arrangements. Members are also responsible for any transportation and lodging expenses in excess of $500 and any penalties/fees incurred due to member changes. Calvo's SelectCare will reimburse members up to the $500 allowance under this travel benefit.

FEHB members covered by Medicare: Medicare beneficiaries may only receive services at a Plan participation Medicare-contracted facility in Guam, Saipan, Hawaii, and the continental United States. Medicare eligible care and services which are rendered at a facility which is not a Medicare contracted facility or which is rendered by a physician who is not a Medicare contracted physcian will not be covered. FEHB members with Medicare as their primary payer are not eligible for the Travel Benefit to the Philippines or Taiwan.

A fifty percent (50%) discount is offered for air ambulance transportation services from Guam, the CNMI, and Palau to the Philippines, Japan, Taipei, or Honolulu for certain qualifying medical conditions. Pre-arrangements must be made with the plan and the air ambulance company.

Gym Membership

Calvo's SelectCare provides 100% coverage of the cost of gym memberships (subscribers and dependents) only at partner fitness centers . Coverage is limited to benefit year (January to December 2021). Members are limited to enrolling in one partner gym per year.

Calvo's Lifestyle Club Membership

The Lifestyle Club is a Membership Rewards Program for Calvo's SelectCare FEHB members (subscriber and one adult dependent only). Members enjoy benefits and discounts from participating shopping, dining, gym, gas partners.

Go to www.calvosinsurance.com for more information about the program.

Wellness Incentives

Calvo's SelectCare provides a program that offers members the encouragement and rewards to help members, 18 years old and above, improve or maintain their health. The Plan offers multiple wellness incentives that will allow members to earn up to a maximum  of $75 per member, $150 per self plus one enrollment and $200 for self and family enrollment per benefit year for completing preventive services such as the online health risk assessment, annual physicals, doctor's visits for chronic conditions, breast cancer screening, cervical cancer screening, colorectal cancer screening, and smoking cessation classes.

Incentive amounts will be calculated 60 days after the end of the current policy period and checks will be processed within 30 days after the calculation date. Members must complete a claim reimbursement form and submit to Calvo’s SelectCare along with proper documentation in order to claim benefit. Claims must be submitted to us no later than 90 days after the end of the policy period.

Supplemental Dental Coverage

Calvo's SelectCare offers a dental plan to supplement the dental coverage provided in the Calvo's SelectCare FEHB plan option you have selected. Supplemental dental coverage will be coordinated with your FEHB dental coverage. Enrollment in supplemental dental coverage is required every Open Season. This coverage does not automatically renew.

The supplemental dental plan provides coverage as follows:

Medical and hospital benefits

In most cases, providers and facilities file claims for you. Provider must file on the form HCFA-1500, Health Insurance Claim Form. Your facility will file on the UB-92 form. For claims questions and assistance, call us at 671-477-9808.

When you must file a claim – such as for services you received outside the Plan’s service area and/or from non-participating providers – submit it on the HCFA-1500 or a claim form that includes the information shown below. Claims forms, bills and receipts should be itemized, translated in English when originals are in another language and show:

• Covered member’s name 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;
• Medications
• 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;
• Medical records

Mail your claims to:    Calvo's SelectCare Customer Service, P.O. Box FJ, Hagatna, Guam   96932

Or

Submit your claims at: Calvo's SelectCare Customer Service, 115 Chalan Santo Papa, Hagatna, Guam 96910           

Mail your claims to: Calvo's SelectCare Customer Service, P.O. Box FJ, Hagatna, Guam 96932

Or

Submit your claims at: Calvo's SelectCare Customer Service, 115 Chalan Santo Papa, Hagatna, Guam 96910

Mail your claims to: Calvo's SelectCare Customer Service, P.O. Box FJ, Hagatna, Guam 96932

Or

Submit your claims at: Calvo's SelectCare Customer Service, 115 Chalan Santo Papa, Hagatna, Guam 96910

Deadline for filing your claim

Send us all of the documents for your claim as soon as possible. You must submit the claim and all required information (translated in English when originals are in another language) 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, we will permit a health care 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.

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 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 health care 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 Calvo's SelectCare Customer Service Department, P.O. Box FJ, Hagatna, Guam 96932; 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 our 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 your 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, Health Insurance 3, 1900 E Street, NW, Washington DC 20415-3630.

Send OPM the following information:

• A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
• Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms:
• Copies of all letters you sent to us about the claim; 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 fo file a disputed claim with OPM. Parties acting as you representative, such as medical providers, must include a copy of your specific written consent with the review request. However, for urgent care claims, a health care professional with knowledge of your medical condition may act as your authorized representative without yrou express consent.

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

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

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

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

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

When you have other health coverage

You must tell us if you or a covered family member have coverage under any other health plan or have automobile insurance that pays health care 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’ guidelines. For more information on NAIC rules regarding the coordinating of benefits, visit our website at www.calvos.net.

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 pays, 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 health care 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 Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under TRICARE or CHAMPVA.

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.

Our right to pursue and receive subrogation and reimbursement recoveries is a condition of, and a limitation on, the nature of 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, judgement, or otherwise.

We are entitled to reimbursement to the extent of the benefits we have paid or provided in connections 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 judgement, 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.

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

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

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

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) 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.

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. You will not need to do anything. To find out if you need to do something to file your claim, call us at 671-477-9808 or see our Web site at www.calvos.net.

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

• Medical services and supplies provided by physicians and other health care professionals
• Outpatient surgery

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. Members must use providers who accept Medicare's assignment.

Benefit Description: Deductible
You pay without Medicare: $0
You pay with Medicare Part B: $0

Benefit Description: Primary Care Physician
You pay without Medicare: $15 copay High Option / $20 copay Standard Option
You pay with Medicare Part B: $0

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

Benefit Description: Inpatient Hospital 
You pay without Medicare: $200 copayment High Option / 20% coinsurance Standard Option
You pay with Medicare Part B: $$200 copayment High Option / 20% coinsurance Standard Option

Benefit Description: Outpatient Surgery -Hospital
You pay without Medicare: $100 copay (includes professional fees) High Option / 20% coinsurance Standard Option
You pay with Medicare Part B: $0

Benefit Description: RX (30-day supply)
You pay without Medicare: High Option: $10 for generic, $25 for preferred brand, 50% of AWP for non-preferred brand, $100 for Specialty Standard Option:$20 for generic, $40 for preferred brand, $100 for non-preferred brand, $250 for Specialty
You pay with Medicare Part B: High Option: $10 for generic, $25 for preferred brand, 50% of AWP for non-preferred brand, $100 for Specialty Standard Option:$20 for generic, $40 for preferred brand, $150 for non-preferred brand, $250 for Specialty

Benefit Description: RX - Mail order (90-day supply - one copay)
You pay without Medicare: High Option: $10 for generic, $25 for preferred brand, 50% of AWP for non-preferred brand, $200 for Specialty 
Standard Option:$20 for generic, $40 for preferred brand, $100 for non-preferred brand, $250 for Specialty
You pay with Medicare Part B: High Option: $10 for generic, $25 for preferred brand, 50% of AWP for non-preferred brand, $200 for Specialty Standard Option:$20 for generic, $40 for preferred brand, $100 for non-preferred brand, $250 for Specialty

You can find more information about how our plan coordinates benefits with Medicare at www.calvos.net.

• 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 health care choices (like HMOs and regional PPOs) in some areas of the country. To learn more about Medicare Advantage plans, contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at www.medicare.gov.

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

This Plan and 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.

• Medicare prescription drug coverage (Part D)

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

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

Coinsurance

See Section 4, page 23.

Copayment

See Section 4, page 23.

Cost-sharing

See Section 4, page 23.

Helps you meet your daily living activities. This type of care does not require the continuing attention and assistance of licensed medical or trained paramedical personnel. Custodial care lasting 90 days or more is sometimes known as long term care.

Deductible

See Section 4, page  23.

Services, supplies, devices, procedures, drugs, or treatment that is not yet accepted as common medical practice.

An insurance plan that provides health care coverage to a select group of people

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

Medical necessity refers to medical services or hospital services which are determined by us to be:

• Rendered for the treatment or diagnosis of an injury or illness; and
• Appropriate for the symptom, consistent with diagnosis, and otherwise in accordance with sufficient scientific evidence and professionally recognized standards; and
• Not furnished primarily for the convenience of the member, the attending physician, or other provider of service; and 
• Furnished in the most economically efficient manner which may be provided safely and effectively to the member.

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 as follows:

The payment we would make if the healthcare services had been obtained within our Service Area and/or by an In-Network provider, or a special negotiated payment or Medicare rates

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.

Pre-service claims

Those claims (1) that require precertification, prior approval, or a referral and (2) where failure to obtain precertification, prior approval, or a referral results in a reduction of benefits.

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 a 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.

Subrogation

A carrier's pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, as successor to the rights of a covered individual who suffered an illness or injury and has obtained benefits from that carrier's health benefits plan.

Us and We refer to Calvo's SelectCare

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 without the care or treatment that is the subject of the claim.

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

If you believe your claim qualifies as an urgent care claim, please contact our Customer Service Department by telephone at 671-477-9808 or by mail at P.O. Box FJ, Hagatna, Guam 96932. 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 doctor's office

High Option

In-network: $15 copayment per PCP office visit; $40 copayment per specialist visit

Preferred In-network: $5 copayment per PCP office visit

Standard Option

In-network: $20 copayment per PCP office visit; $40 copayment per specialist visit

 Preferred In-network: $10 copayment per PCP office visit

26

Services provided by a hospital:

• Inpatient

High Option

In-network: $200 copayment per inpatient hospital admission (includes doctors' services)

Standard Option

In-network: 20% coinsurance per inpatient hospital admission

57

Services provided by a hospital:

• Outpatient

High Option

In-network: $100 copayment per outpatient surgical facility (includes doctors' services)

Standard Option

In-network: 20% coinsurance per outpatient surgical facility visit

58

Emergency benefits:

• In-area

High Option

$100 copayment per emergency room visit (hospital)

Standard Option

20% coinsurance per emergency room visit (hospital)

60

Emergency benefits:

• Out-of-area

High Option

$200 copayment per emergency room visit (hospital) and any difference between eligible charges and billed charges

Standard Option

20% coinsurance per emergency room visit (hospital) and any difference between eligible charges and billed charges

61

Mental health and substance misuse disorder treatment:

High and Standard Options

Member's cost-sharing responsibilities are no greater than for other illnesses or conditions.

63

Prescription drugs:

• Retail pharmacy (30-day supply)

High Option

$10 copayment for Generic 

$25 copayment for Preferred Brand 

50% of Average Wholesale Price (AWP) for Non-Preferred Brand 

$100 copayment for Specialty 

Standard Option

$15 copayment for Generic 

$40 copayment for Preferred Brand 

50% of Average Wholesale Price for Non-Preferred

$150 copayment for Specialty 

66

Dental care:

High Option

Nothing for preventive dental care

Standard Option

Nothing for preventive dental care

70

Vision care:

High Option

In-network: $15 copayment per PCP visit, $40 per specialist visit for annual eye exam (includes refraction)

Standard Option

In-network: $20 copayment per PCP visit, $40 per specialist visit for annual eye exam (includes refraction)

42

Special Features: Airfare Benefit 

High and Standard Options
When criteria are met and when approved in advance by Calvo’s SelectCare, the Airfare Benefit covers only the economy round-trip airfare for the member, a medical attendant and a companion, if required. This benefit cannot be used in conjunction with the Travel Benefit.

71

Special Features: Wellness Incentives

High and Standard Options
Incentives to reward you for completing a Health Risk Assessment (HRA) and other selected health screenings.

73

Special Features: Travel Benefit

High and Standard Options
The Plan will reimburse members up to $500 (one time per member per year) for round-trip airfare, ground transportation, or lodging in the Philippines. This benefit covers pre-authorized, elective in-patient or out-patient procedures at participating providers in the Philippines, excluding emergencies, preventive services, home health, hospice, or maternity-related services. This benefit cannot be used in conjunction with Airfare Benefit.

71

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

High Option

Medical - Nothing after $2,000 for Self Only, $4,000 for Self Plus One, and $6,000 for Self and Family

Prescription Drugs - Nothing after $2,000 for Self Only and $4,000 for Self Plus One and Self and Family

Standard Option

Medical - Nothing after $3,000 for Self Only, $6,000 for Self Plus One, and $8,000 for Self and Family

Prescription Drugs - Nothing after $2,000 for Self Only and $4,000 for Self Plus One and Self and Family 

13