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

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

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

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

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

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

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

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

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

Contact your carrier to add a family member when there is already family Coverage.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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 Temporary Continuation of Coverage (TCC); or a conversion policy (a non-FEHB individual policy)

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 additional 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.

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

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

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

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

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

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

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

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed and your coverage will not be limited due to pre-existing conditions.  When you contact us, we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act’s Health Insurance Marketplace in your state. For assistance in finding coverage, please contact us at 800-235-8631 or visit our website at www.anthem.com/ca.

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

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

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 800-235-8631 or write to us at Anthem Blue Cross Select HMO, P.O. Box 60007, Los Angeles, CA. 90060-0007. You may also request replacement cards through our website at  www.anthem.com/ca.

You get care from “Plan providers” and “Plan facilities.” You will only be responsible for your cost-sharing (copayments, coinsurance, deductibles, and non-covered services and supplies).

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

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

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

This plan provides Care Coordinators for complex conditions and can be reached by calling 800-235-8631 or www.anthem.com/ca for assistance.

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

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

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.

Your primary care physician can be a general or family practitioner, internist or pediatrician. Your primary care physician will provide most of your healthcare, or give you a referral to see a specialist.

If you want to change primary care physicians or if your primary care physician leaves the plan, call us. We will help you select a new one.

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.

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 they decide to refer you to a specialist, ask if you can see your current specialist.
  
  If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.
• If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist.  You may receive services from your current specialist until we can make arrangements for you to see someone else
• If you have a chronic and disabling condition and lose access to your specialist because we:
  • terminate our contract with your specialist for other than cause;
  • drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB program plan; or
  • reduce our service 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.

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

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our plan begins, call our customer service department immediately at 800-235-8631. If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

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

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

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

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

Prior Plan approval must be obtained in advance in order for transgender services to be covered.

Certain providers have been designated to provide transgender services.  If a Plan provider is not available you will need to obtain an authorized referral in order for services to be covered.  See Section 3. How to request precertification for an admission or get prior authorization for Other services.  See Section 5(b) Reconstructive surgery.

Medical necessity criteria for; hysterectomy, salpingo-oophorectomy; ovariectomy , or orchiectomy:

1. The individual is at least 18 years of age; and

2. The individual has capacity to make fully informed decisions and consent for treatment; and

3. The individual has been diagnosed with gender dysphoria and exhibits all of the following:

• The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make their body as congruent as possible with the preferred sex through surgery and hormone treatment; and
• The transsexual identity has been present persistently for at least two years; and
• The disorder is not a symptom of another mental disorder; and
• The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; and

4. If the individual has significant medical or mental health issues present, they must be reasonably well controlled.  If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (for example, psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated; and

5. Two referrals from qualified mental health professionals who have independently assessed the individual. If the first referral is from the individual's psychotherapist, the second referral should be from a person who has only had an evaluative role with the individual. Two separate letters, or one letter signed by both (for example, if practicing within the same clinic) are required.

Medical necessity criteria for; metoidioplasty, phalloplasty, vaginoplasty, penectomy, clitoroplasty, labiaplasty, vaginectomy, scrotoplasty, urethroplasty, or placement of testicular prostheses:

1. The individual is at least 18 years of age; and

2. The individual has capacity to make fully informed decisions and consent for treatment; and

3. The individual has been diagnosed with gender dysphoria and exhibits all of the following:

• The desire to live and be accepted as a member of the opposite sex, usually accompanied by the wish to make their body as congruent as possible with the preferred sex through surgery and hormone treatment; and
• The transsexual identity has been present persistently for at least two years; and
• The disorder is not a symptom of another mental disorder; and
• The disorder causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; and

4. Individuals without a medical contraindication or otherwise unable or unwilling to take hormones, the individual has undergone a minimum of 12 months of continuous hormonal therapy when recommended by a mental health professional and provided under the supervision of a physician; and

5. Documentation that the individual has completed a minimum of 12 months of successful continuous full time real-life experience in their new gender, across a wide range of life experiences and events that may occur throughout the year (for example, family events, holidays, vacations, season-specific work or school experiences).  This includes coming out to partners, family, friends, and community members (for example, at school, work, and other settings).
Note:
- The medical documentation should include the start date of living full time in the new gender
- Verification via communication with individuals who have related to the individual in an identity-congruent gender role, or requesting documentation of a legal name change, may be reasonable in some cases; and

6. Regular participation in psychotherapy throughout the real-life experience when recommended by a treating medical or behavioral health practitioner; and

7. If the individual has significant medical or mental health issues present, they must be reasonably well controlled.  If the individual is diagnosed with severe psychiatric disorders and impaired reality testing (for example, psychotic episodes, bipolar disorder, dissociative identity disorder, borderline personality disorder), an effort must be made to improve these conditions with psychotropic medications and/or psychotherapy before surgery is contemplated; and

8. Two referrals from qualified mental health professionals who have independently assessed the individual. If the first referral is from the individual's psychotherapist, the second referral should be from a person who has only had an evaluative role with the individual. Two separate letters, or one letter signed by both (for example, if practicing within the same clinic) are required.

Note:  At least one of the professionals submitting a letter must have a doctoral degree (Ph.D., M.D., Ed.D., D.Sc., D.S.W., or Psy.D) and be capable of adequately evaluating co-morbid psychiatric conditions. One letter is sufficient if signed by two providers, one of whom has met the doctoral degree specifications, in addition to the specifications set forth above.

Gender reassignment surgery is considered not medically necessary when one or more of the criteria above have not been met.

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.

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

First, your physician, your hospital, you, or your representative, must call the toll-free telephone number on the back of your member ID card before admission or services requiring prior authorization are rendered.

Next, provide the following information:

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

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

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

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

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

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

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM.  Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 800-235-8631.  You may also call OPM’s FEHB 2 at 202-606-3818 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review.  We will cooperate with OPM so they can quickly review your claim on appeal.  In addition, if you did not indicate that your claim was a claim for urgent care, call us at 800-235-8631. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

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

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

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

If you 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.

• When services are not reviewed before or during the time you receive the services, we will review those services when we receive the bill for benefit payment.  If that review determines that part or all of the services were not medically necessary and appropriate, we will not provide benefits for those services.
•  If you receive authorized referral services from a non-Plan provider, the Plan provider copay will apply.  When you do not get a referral, no benefits are provided for services received from a non-Plan provider.

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 your claim is in reference to a contraceptive, call 833-261-2459.

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

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

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

• 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
• 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.
• Write to you and maintain our denial

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

Unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request.  We will expedite the review process, which allows oral or written requests for appeals and the exchange of information by telephone, 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 is the general term used to refer to your out-of-pocket costs (e.g., deductible, if any, coinsurance, and copayments) for the covered care you receive.

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

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

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

After your copayments total $3,000 for Self Only or $3,000 per person for Self Plus One, or $6,000 for Self and Family enrollment in any calendar year, you do not have to pay any more for covered services. However, copayments or coinsurance for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments or coinsurance for these services:

• Infertility services

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

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

The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” under certain circumstances. A surprise bill is an unexpected bill you receive from a nonparticipating healthcare provider, facility, or air ambulance service for healthcare. Surprise bills can happen when you receive emergency care – when you have little or no say in the facility or provider from whom you receive care. They can also happen when you receive non-emergency services at participating facilities, but you receive some care from nonparticipating providers.

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

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

In addition, your health plan adopts and complies with the surprise billing laws of California.

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to https://www.anthem.com/ca/no-surprise-billing/ or contact the health plan at 800-235-8631.

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

Professional services of physicians

• In physician’s office
• Home visits
• Office medical consultations
• Second opinion

$30 per PCP visit

$40 per Specialist visit

• During a hospital stay
• In a skilled nursing facility

• In an urgent care center
• In a Retail Health Clinic

• Injectable or infused medications given by the doctor in the office

This does not include immunizations prescribed by your primary care physician nor allergy serum

Not covered:

• Consultations given using telephones, facsimile machines, or electronic mail.
• Services for your personal care, such as: helping in walking, bathing, dressing, feeding, or preparing food. Any supplies for comfort, hygiene or beauty purposes.

Virtual Telehealth /Telemedicine Visits from our Online Provider - LiveHealth Online - Includes non-preventive Medical Services & non-preventive MH/SA Services

Note:  To get started visit the website at www.livehealthonline.com  or Connect using the Sydney Health mobile app

$10 per visit

PCP Medical Virtual Telehealth / Telemedicine Visits

$30 per visit

SPC Medical Virtual Telehealth/Telemedicine Visits

$40 per visit

Virtual Telehealth/Telemedicine Visits for Specialty Care from our Online Provider, LiveHealth Online - (Sleep medicine clinics)

$40 per visit

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine pap test
• Pathology
• X-ray
• Non-routine mammogram
• Ultrasound
• Electrocardiogram and EEG

For the following services:

• Advanced imaging procedures

Advanced Imaging Procedures are imaging procedures, including, but not limited to: Magnetic Resonance Imaging (MRI), Computerized Tomography (CT/CAT scans), Positron Emission Tomography (PET scan), Magnetic Resonance Spectroscopy (MRS scan), Magnetic Resonance Angiogram (MRA scan), Echocardiography, and nuclear cardiac imaging.

For a complete list of advanced imaging procedures or if you need more information, please contact your medical group.

Routine physical every year

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

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

Routine mammogram

Nothing

Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule.

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

Nothing

Not covered:

• Immunizations needed to travel outside the USA or work-related exposure.
• Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.
• Wilderness or other outdoor camps and/or programs. This exclusion does not apply to medically necessary services to severe mental disorders or serious emotional disturbances of a child, as required by state or federal law.

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

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

Not covered:

• Immunizations needed to travel outside the USA or work-related exposure.
• Routine physical or psychological exams or tests asked for by a job or other group, such as a school, camp, athletic exams, or sports program.
• Wilderness or other outdoor camps and/or programs. This exclusion does not apply to medically necessary services to severe mental disorders or serious emotional disturbances of a child, as required by state or federal law.

Complete maternity (obstetrical) care, such as:

• Prenatal care and Postnatal care

• Screening for gestational diabetes
• Delivery

Nothing

Note:  You owe a hospital admission copay for inpatient hospital services.

Breastfeeding support, supplies and counseling for each birth

Note:  Here are some things to keep in mind:

• You do not need to preauthorize your vaginal delivery
• You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary.
• We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. Newborn circumcision is covered under Surgery benefits (see Section 5(b)).
• We pay hospitalization and surgeon services (delivery) the same as for illness and injury. 
• Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b). 

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

Not covered:

• For any services or supplies provided to a person not covered under the plan in connection with a surrogate pregnancy (including, but not limited to, the bearing of a child by another woman for an infertile couple).

A range of voluntary family planning services,limited to:

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

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

• Voluntary sterilization (See Surgical Procedures Section 5 (b))

• Family planning visits

$30 per office visit

Genetic testing, when medically necessary

Not covered:

• Reversal of voluntary surgical sterilization
• Over-the-counter contraceptives will not be covered unless a prescription is provided.

Diagnosis and treatment of infertility such as:

• Artificial insemination (AI):
  • Intravaginal insemination (IVI)
  • Intracervical insemination (ICI)
  • Intrauterine insemination (IUI)
• Fertility preservation services to prevent iatrogenic infertility when medically necessary.

Note: We cover injectable fertility drugs under medical benefits. See Section 5(f) Prescription drugs benefits for oral fertility drugs. 

Not covered:

• Infertility services after voluntary sterilization
• Assisted reproductive technology (ART) procedures, such as:
  • in vitro fertilization (IVF)
  • embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)
• Services and supplies related to ART procedures
• Cost of donor sperm
• Cost of donor egg
• Fertility drugs

• Testing and treatment

• Allergy injections including serum

• Chemotherapy

$40 per visit

• Radiation therapy

$40 per visit

• Visits for cardiac rehabilitation limited to 36 visits

$40 per visit

• Respiratory/inhalation therapy

$40 per visit

• Pulmonary rehabilitation

$40 per visit

• Hemodialysis including treatment at home if approved by the medical group

$40 per visit

• Infusion therapy (home IV and antibiotic therapy)

$40 per visit

• Applied Behavior Analysis (ABA) – Children with autism spectrum disorder

$30 per visit

• Medical social services
• Growth hormone therapy

• Visits for rehabilitative and habilitative physical and occupational therapy

You may have up to a 60 day period of care after an illness or injury.  The 60 day period of care starts with the first visit for rehabilitative and habilitative care.  The 60 day limit does not limit the number of visits or treatments you get within the 60 day period.  If you need more than the 60 day period of care, your primary care physician must get the approval from your medical group or Anthem.  It must be shown that more care is medically necessary.  Your medical group or Anthem will approve the extra visits or treatments.

Note:  We only cover therapy when a physician:

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

$40 per visit

Not covered:

• Treatment of frequent recurrences of pain, over a long period of time,  that is not related to an active medical condition currently being treated.
• Health club memberships, exercise equipment, charges from a physical fitness instructor or personal trainer, or any other charges for activities, equipment, or facilities used for developing or maintaining physical fitness, even if ordered by a doctor.  This exclusion also applies to health spas.
• Programs to help you change how you live, like fitness clubs, or dieting programs. This does not apply to cardiac rehabilitation programs approved by your medical group

• Visits for rehabilitative and habilitative speech therapy by a licensed speech therapist when prescribed by your physician

Not covered:

• Aids for Non-verbal Communication. Devices and computers to assist in communication and speech except for speech aid devices and tracheoesophageal voice devices approved by Anthem are not covered.

All charges

• Vision screening includes a vision check by your primary care physician to see if it is medically necessary for you to have a complete vision exam by a vision specialist. If approved by your primary care physician, this may include an exam with diagnosis, a treatment program and refractions.

Nothing

Not covered:

• Eyeglasses or contact lenses. Contact lens fitting is not covered. Except as stated under Orthopedic and prosthetic devices
• Eye exercises and orthoptics
• Radial keratotomy and other refractive surgery

• We cover medically necessary care for the diagnosis and treatment of conditions of the foot, when prescribed by your physician.

Not covered:

• Routine foot care

You can get devices to take the place of missing parts of your body.

• Surgical implants
• Artificial limbs and eyes
• Breast prostheses following a mastectomy
• The first pair of contact lenses or eyeglasses when needed after a covered and medically necessary eye surgery
• Prosthetic devices to restore a method of speaking when required as a result of a laryngectomy
• Colostomy supplies
• Therapeutic shoes and inserts designed to prevent foot complications due to diabetes
• Orthopedic footwear used as an integral part of a brace; shoe inserts that are custom molded to the patient
• Supplies needed to take care of these devices
• Breast prostheses and surgical bras following a mastectomy

Not covered:

• Orthopedic shoes (except when joined to braces) or shoe inserts (except custom molded orthotics).  This does not apply to shoes and inserts designed to prevent or treat foot complications due to diabetes.

You can get long-lasting medical equipment (called durable medical equipment) and supplies that are rented or bought for you if they are:

• Ordered by your primary care physician.
• Used only for the health problem.
• Used only by the person who needs the equipment or supplies.
• Made only for medical use.

• You can get certain diabetic equipment and supplies as described by a physician

50% of Plan allowance

• You can also get nebulizers, including face masks and tubing for treatment of pediatric asthma.

Note:  These items are not subject to any limits or maximums that apply to coverage for medical equipment.

• Special food products and formulas that are part of a diet prescribed by a doctor for the treatment of phenylketonuria (PKU).

You can get most formulas used in the treatment of PKU from a drugstore.  These are covered under your plan’s benefits for prescription drugs (see Section 5(f)).  Special food products that are not available from a drugstore are covered as medical supplies under your plan’s medical benefits.

Equipment and supplies are not covered if they are:

• Only for your comfort or hygiene.
• For exercise.
• Only for making the room or home comfortable, such as air conditioning or air filters.
• Scalp hair prostheses, including wigs or any form of hair replacement.
• Nutritional and/or dietary supplements, except as provided in this Plan or as required by law.  This exclusion includes, but is not limited to, those nutritional formulas and dietary supplements that can be purchased over the counter, which by law do not require either a written prescription or dispensing by a licensed pharmacist.
• Disposable supplies for use in the home such as bandages, gauze, tape, antiseptics, dressings, ace-type bandages, and any other supplies, dressings, appliances or devices that are not specifically listed as covered.
• Consumer wearable/personal mobile devices (such as a smart phone, smart watch, or other personal tracking devices), including any software or applications.

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

Note:  For routine hearing screenings performed during a preventive care visit, see Section 5(a) Preventive care services, adult and Preventive care services, children.

• External hearing aids
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants.

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

We will cover home healthcare furnished by a home health agency (HHA) for up to 100 visits in a calendar year.

• Care from a registered nurse or licensed vocational nurse who works under a registered nurse or a doctor
• Private duty nursing

$40 per visit

• Physical therapy, occupational therapy, speech therapy, or respiratory therapy

$40 per visit

• Visits with a medical social service worker

$40 per visit

• Care from a health aide who works under a registered nurse with the HHA (one visit equals four hours or less)

$40 per visit

• Oxygen therapy, intravenous therapy and medications

$40 per visit

• Medically necessary supplies from the HHA

  Note: In-home intensive behavioral health visits are covered if available in your area. See Section 5(e).

Covered up to 20 visits in a year when you see a chiropractor in the American Specialty Health Plans of California, Inc. (ASH Plans) network.

Also up to $50 per calendar year in rental or purchase charges are covered for medical equipment and supplies ordered by an ASH Plans chiropractor, and approved as medically necessary by ASH Plans. Such medical equipment includes: (1) elbow supports, back supports (thoracic), lumbar braces and supports, rib supports, or wrist supports; (2) cervical collars or cervical pillows; (3) ankle braces, knee braces, or wrist braces; (4) heel lifts; (5) hot or cold packs; (6) lumbar cushions; (7) rib belts or orthotics; and (8) home traction units for treatment of the cervical or lumbar regions.

Note: The ASH Plans chiropractor is responsible for obtaining the necessary approval from the Plan.

Not covered:

• Any services provided by ASH Plans that are not approved by us, except for the first visit
• The services of a non-ASH Plans chiropractor

Acupuncture – 20 visits per calendar year if referred by your primary care physician

$40 per session

Not covered:

• Acupressure, or massage to help pain, treat illness or promote health by putting pressure to one or more areas of the body

Coverage is provided for:

• Diabetes education program services supervised by a doctor which include; a) teaching you and your family members about the disease process and how to take care of it; and b) training, education, and nutrition therapy to enable you to use the equipment, supplies, and medications needed to manage the disease.

$40 per class 

• Nutritional counseling for the treatment of obesity
• Childhood obesity screening programs and treatment interventions

• Tobacco cessation programs for nicotine dependency.  We cover medically necessary drugs for nicotine dependency that require a prescription.  This does not include those services required under the “Preventive Care Services” benefit.

Note: See Section 5(f) Prescription benefits for information on physician prescribed OTC and prescription drugs approved by the FDA to treat tobacco cessation. See Section 5(e) for information on individual and group psychotherapy.

Nothing

• Pediatric asthma education program

$40 per class

Routine patient care costs, as defined below, for phase I, phase II, phase III and phase IV cancer clinical trials.

All of the following conditions must be met:

• The treatment you get in a clinical trial must either:
  • Involve a drug that is exempt under federal regulations from a new drug application, or
  • Be approved by (i) one of the National Institutes of Health, (ii) the federal Food and Drug Administration in the form of an investigational new drug application, (iii) the United States Department of Defense, or (iv) the United States Veteran’s Administration.
• You must have cancer to be able to participate in these clinical trials.
• Participation in these clinical trials must be recommended by your primary care doctor after deciding it will help you.  If the clinical trial is not provided by or through your medical group, your primary care doctor will refer you to the doctor or healthcare provider who provides the clinical trial.  Please see “When You Need a Referral” in the section called “When You Need Care” for information about referrals.  You will only have to pay your normal copays for the services you get.
• For the purpose of this provision, a clinical trial must have a therapeutic intent.  Clinical trials to just test toxicity are not included in this coverage.

$30 per PCP office visit

$40 per Specialist office visit

Routine patient care cancer clinical trials costs are the costs associated with the services provided, including drugs, items, devices and services which would otherwise be covered under the plan, including healthcare services which are:

• Typically provided absent a clinical trial.
• Required solely to provide the investigational drug, item, device or service.
• Clinically appropriate monitoring of the investigational item or service.
• Prevention of complications arising from the provision of the investigational drug, item, device, or service.
• Reasonable and necessary care arising from the provision of the investigational drug, item, device, or service, including the diagnosis or care of the complications.

$30 per PCP office visit

$40 per Specialist office visit

Routine patient care cancer clinical trials costs do not include any of the costs associated with any of the following:

• Drugs or devices not approved by the Federal Food and Drug Administration that are part of the clinical trial.
• Services other than healthcare services, such as travel, housing, companion expenses and other nonclinical expenses that you may need because of the treatment you get for the purposes of the clinical trial.
• Any item or service provided solely to satisfy data collection and analysis needs not used in the clinical management of the patient.
• Healthcare services that, except for the fact they are provided in a clinical trial, are otherwise specifically excluded from the plan.
• Healthcare services usually provided by the research sponsors free of charge to members enrolled in the trial.

Note:  You will pay for costs of services that are not covered.

$30 per PCP office visit

$40 per Specialist office visit

$30 per PCP office visit

$40 per Specialist office visit

Not covered:

• Any investigational drugs or devices, non-health services required for you to receive the treatment, the costs of managing the research, or costs that would not be a covered service under this plan for non-Investigative treatments, unless specifically stated.

All charges

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Any medically necessary eye surgery
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Treatment of burns
• Correction of congenital anomalies (see Reconstructive surgery)
• Insertion of internal prosthetic devices. See 5(a) – Orthopedic and prosthetic devices for device coverage information.

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

Nothing

Surgical treatment of morbid obesity (bariatric surgery) as determined by your medical group, when the treatment is approved in advance. In order for your medical group to consider you for this surgery, you must:

• Have a Body Mass Index of 40 or greater, or Body Mass Index of 35 or greater with co-morbid conditions including, but not limited to, life threatening cardio-pulmonary problems (severe sleep apnea, Pickwickian syndrome and obesity related cardiomyopathy), severe diabetes mellitus, cardiovascular disease or hypertension; and
• Have actively participated in non-surgical methods of weight reduction; and
• Have a psychiatric profile that will allow you to understand, tolerate and comply with all phases of care and are committed to long-term follow-up requirements.

Note:  Before the bariatric surgery can be approved, your medical group must address post-operative expectations and give you a thorough explanation of the risks and benefits of the procedure.

Not covered:

• Any eye surgery just for correcting vision (like nearsightedness and/or astigmatism). Contact lenses and eyeglasses needed after this surgery
• Surgery done to reverse sterilization
• Services not stated above as covered
• Routine treatment of conditions of the foot (see Foot care)

• Reconstructive surgery performed to correct deformities caused by congenital or developmental abnormalities, illness, or injury for the purpose of improving bodily function, reducing symptoms or creating a normal appearance, including medically necessary dental or orthodontic services that are an integral part of reconstructive surgery for cleft palate procedures.  “Cleft palate” means a condition that may include cleft palate, cleft lip, or other craniofacial anomalies associated with cleft palate.
• Mastectomy and lymph node dissection; complications from a mastectomy including lymphedema.
• Reconstructive surgery of both breasts performed to restore symmetry following a mastectomy.

Medically necessary Gender Reassignment Surgical services to treat gender dysphoria will be covered as follows (See Section 3 for medical necessity criteria):

• Gender Affirming surgery, consisting of any combination of the following; hysterectomy, salpingo-oophorectomy; ovariectomy , or orchiectomy are considered medically necessary when all of the medical necessity criteria are met;  or
• Gender Affirming surgery, consisting of any combination of the following; metoidioplasty, phalloplasty, vaginoplasty, penectomy, clitoroplasty, labiaplasty, vaginectomy, scrotoplasty, urethroplasty, or placement of testicular prostheses are considered medically necessary when all of the medical necessity criteria are met.

Not covered:

• Cosmetic Surgery.  Surgery or other services done only to make you a) look beautiful; b) to improve your appearance;  or c) to change or reshape normal parts or tissues of the body.

This does not apply to reconstructive surgery you might need to a) give you back the use of a body part; b) have for breast reconstruction after a mastectomy; and c) correct or repair a deformity caused by birth defects, abnormal development, injury or illness in order to improve function, symptomatology or create a normal appearance.

Cosmetic surgery does not become reconstructive because of psychological or psychiatric reasons.

• Treatment of varicose veins or telangiectatic dermal veins (spider veins) by any method (including sclerotherapy or other surgeries) when services are rendered for cosmetic purposes.
• Surgeries that are considered cosmetic when used to improve the gender specific appearance of an individual who has undergone or is planning to undergo gender reassignment surgery include:
  • Reduction thyroid chondroplasty
  • Liposuction
  • Rhinoplasty
  • Facial bone reconstruction
  • Face lift
  • Blepharoplasty
  • Voice modification surgery
  • Hair removal/hairplasty
  • Breast augmentation

Oral surgical procedures, limited to:

• Reduction of fractures of the jaws or facial bones;
• Removal of stones from salivary ducts;
• Excision of leukoplakia or malignancies;
• Excision of cysts and incision of abscesses when done as independent procedures;
• Splint therapy or surgical treatment for disorders of the joints linking the jawbones and the skull (the temporomandibular joints); including the complex of muscles, nerves and other tissues related to those joints; and
• Other surgical procedures that do not involve the teeth or their supporting structures.

Not covered:

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

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. See Other services under You need prior Plan approval for certain services in Section 3.  Solid organ transplants are limited to:

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

Blood or Marrow Stem Cell Transplants:

The Plan extends coverage for the diagnoses as indicated below.

• Allogeneic transplants for:
• Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
• Acute myeloid leukemia
• Advanced Hodgkin's lymphoma with recurrence (relapsed)
• Advanced Myeloproliferative Disorders (MPDs)
• Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
• Amyloidosis
• Chronic lymphocytic leukemia/small lymphocytic leukemia (CLL/SLL)
• Hemoglobinopathy
• Marrow failure and related disorders (i.e., Fanconi's, PNH, Pure Red Cell Aplasia)
• Myelodysplasia/Myelodysplastic Syndromes
• Paroxysmal Nocturnal Hemoglobinuria
• Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
• Severe combined immunodeficiency
• Severe or very severe aplastic anemia
• Sickle cell anemia
• X-linked lymphoproliferative syndrome
• Autologous transplant for:
• Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
• Advanced Hodgkin's lymphoma recurrence - relapsed or refractory
• Advanced Non-Hodgkin's lymphoma recurrence - relapsed or refractory
• Amyloidosis
• Breast cancer
• Epithelial ovarian cancer
• Neuroblastoma

Blood or Marrow Stem Cell Transplants: Not subject to medical necessity:

• Allogeneic transplant for:
  • Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
• Autologous transplants for:
  • Multiple myeloma
  • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

Blood or Marrow Stem Cell Transplants: Not subject to Medical Necessity.

• Autologous transplants for:
• Advanced childhood kidney cancers
• Advanced Ewing sarcoma
• Aggressive non-Hodgkin’s lymphomas (Mantle Cell lymphoma, adult T-cell leukemia/lymphoma, peripheral T-cell lymphomas and aggressive Dendritic Cell neoplasms)
• Breast cancer
• Childhood rhabdomyosarcoma
• Epithelial ovarian cancer
• Mantle Cell (Non-Hodgkin lymphoma)

Mini-transplants performed in a Clinical Trial Setting (non-myeloablative, reduced intensity conditioning) for members with a diagnosis listed below: Subject to Medical Necessity

• Allogeneic transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Chronic lymphocytic leukemia/small lymphocytic leukemia (CLL/SLL)
  • Hemoglobinopathy
  • Hodgkin’s lymphoma – relapsed
  • Marrow Failure and Related Disorders (i.e., Fanconi’s, PNH, Pure Red Cell Aplasia)
  • Myelodysplasia/Myelodysplastic Syndromes
  • Myeloproliferative Disorders (MPDs)
  • Non-Hodgkin’s lymphoma – relapsed
  • Paroxysmal Nocturnal Hemoglobinuria
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
• Autologous transplants for:
  • Amyloidosis
  • Hodgkin's lymphoma – relapsed
  • Neuroblastoma
  • Non-Hodgkin's lymphoma – relapsed

Tandem transplants for covered transplants: subject to medical necessity review by the Plan.

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

Blood or Marrow Stem Cell Transplants under clinical trials.

• Allogeneic transplants for:
• Beta Thalassemia Major
• Early stage (indolent or non-advanced) small cell lymphocytic lymphoma  
• Mutiple myeloma (after a previous autologous stem cell transplant or due to primary graft failure, failure to engraft or rejection)
• Multiple sclerosis
• Sickle cell  
• Non-myeloablative allogeneic transplants for:
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin's lymphoma
  • Advanced Non-Hodgkin's lymphoma - relapsed or refractor
  • Chronic lymphocytic leukemia
  • Chronic lymphocytic lymphoma/small lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma (after a previous autologous stem cell transplant or due to primary graft failure, failure to engraft or rejection)
  • Multiple sclerosis
  • Myeloproliferative Disorders
  • Myeloproliferative/Myelodysplastic Syndromes
  • Sickle Cell disease
• Autologous transplants for the following autoimmune diseases:
  • Multiple sclerosis
  • Scleroderma
  • Scleroderma-SSc (severe, progressive)
  • Systemic lupus erythematosus
  • Systemic sclerosis
• Autologous transplants for:
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL) (after allogeneic transplant)
  • Chronic myelogenous Leukemia (after allogeneic transplant)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma (after allogeneic transplant)

Blood or Marrow Stem Cell Transplants

• Allogeneic transplants for: 
• Infantile malignant osteopetrosis
• Kostmann’s syndrome
• Leukocyte adhesion deficiencies
• Mucolipidosis (e.g., Gaucher's disease, metachromatic leukodystrophy, adrenoleukodystrophy)
• Mucopolysaccharidosis (e.g., Hunter’s syndrome, Hurler's syndrome, Sanfilippo’s syndrome, Maroteaux-Lamy syndrome variants)
• Myeloproliferative disorders
• Sickle cell anemia
• X-linked lymphoproliferative syndrome
• Autologous transplants for:
• Ependymoblastoma
• Ewing’s sarcoma
• Medulloblastoma
• Pineoblastoma
• Waldenstrom’s macroglobulinemia

National Transplant Program (NTP) – We are a member of the Blue Distinction Center for Transplant.

Not covered:

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

Professional services provided in –

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

Note:  We will consider providing benefits for general anesthesia and facility services related to dental care only when the dental care must be provided in a hospital or ambulatory surgery center because the patient is: 1) less than seven years old; 2) developmentally disabled; or 3) the patient's health is compromised and general anesthesia is medically necessary. We will not cover the dental procedure itself or any of the professional services of a dentist to perform the procedure.

Nothing

Room and board, such as

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

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and X-rays
• Blood transfusions. This includes the cost of blood,
  blood products or blood processing
• Dressings, splints, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services

Note: We will consider providing benefits for general anesthesia and facility services related to dental care only when the dental care must be provided in a hospital or ambulatory surgery center because the patient is: 1) less than seven years old; 2) developmentally disabled; or 3) the patient's health is compromised and general anesthesia is medically necessary. We will not cover the dental procedure itself or any of the professional services of a dentist to perform the procedure.

Services are limited to a 3 day hospital stay. We will not cover the dental procedure itself or any of the professional services of a dentist to perform the procedure.

Not covered:

• Services rendered by hospital resident doctors or interns that are billed separately. This includes separately billed charges for services rendered by employees of hospitals, labs or other institutions, and charges included in other duplicate billings.
• Private duty nursing services given in a hospital or skilled nursing facility.

All charges

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

Note: We will consider providing benefits for general anesthesia and facility services related to dental care only when the dental care must be provided in a hospital or ambulatory surgery center because the patient is: 1) less than seven years old; 2) developmentally disabled; or 3) the patient's health is compromised and general anesthesia is medically necessary. We will not cover the dental procedure itself or any of the professional services of a dentist to perform the procedure.

Nothing unless surgery is performed.

$250 per outpatient surgery admission 

Other outpatient hospital services supplies, including physical therapy, occupational therapy, or speech therapy.

Note: These rehabilitative services are limited to a 60 day period of care after an illness or injury.  If you need more than the 60 day period of care, your primary care doctor must get the approval from your medical group or Anthem.  (See Section 5(a) - Rehabilitative Care.)

$40 per visit

• Chemotherapy
• Radiation therapy
• Hemodialysis treatment
• Infusion therapy

$40 per visit

We cover the following care for a combined benefit of up to 150 days in a calendar year.

• A room with two or more beds
• Special treatment rooms
• Regular nursing services
• Laboratory tests
• Physical therapy, occupational therapy, speech therapy, or respiratory therapy
• Drugs and medications given during your stay. This includes oxygen.
• Blood transfusions
• Needed medical supplies and appliances

• Inpatient rehabilitation care

$250 per day for a maximum of 4 days

Not covered:

• Private duty nursing services given in a hospital or skilled nursing facility.

All charges

We cover the following hospice care if you have an illness that may lead to death. Your primary care physician will work with the hospice and help develop your care plan. The hospice must send a written care plan to your medical group every 30 days.

• Interdisciplinary team care to develop and maintain a plan of care
• Short-term inpatient hospital care in periods of crisis or as respite care. Respite care is provided on an occasional basis for up to five consecutive days per admission
• Physical therapy, occupational therapy, speech therapy and respiratory therapy
• Social services and counseling services
• Skilled nursing services given by or under the supervision of a registered nurse
• Certified home health aide services and homemaker services given under the supervision of a registered nurse
• Diet and nutrition advice; nutrition help such as intravenous feeding or hyperalimentation
• Volunteer services given by trained hospice volunteers directed by a hospice staff member
• Drugs and medications prescribed by a doctor
• Medical supplies, oxygen and respiratory therapy supplies
• Care which controls pain and relieves symptoms
• Bereavement (grief) services, including a review of the needs of the bereaved family and the development of a care plan to meet those needs, both before and after the member’s death. Bereavement services are available to the patient and those individuals who are closely linked to the patient, including the immediate family, the primary or designated care giver and individuals with significant personal ties, for one year after the member’s death.

You can get these services from a licensed ambulance in an emergency or when ordered by your primary care physician. (We will provide benefits for these services if you receive them as a result of a 9-1-1 emergency response system call for help if you think you have an emergency.)  Air ambulance is also covered, but, only if ground ambulance service can’t provide the service needed. Air ambulance service, if medically necessary, is provided only to the nearest hospital that can give you the care you need.

• Base charge and mileage
• Disposable supplies
• Monitoring, EKG’s or ECG’s, cardiac defibrillation, CPR, oxygen, and IV Solutions

$100 per trip

Nothing for all other services and supplies

• Emergency care at a doctor’s office

• Emergency care at an urgent care center

• Emergency care on an outpatient basis at a hospital (if care results in admission to a hospital, the emergency services copayment will not apply)

• Emergency care at a hospital on an inpatient basis

You can get these services from a licensed ambulance in an emergency. (We will provide benefits for these services if you receive them as a result of a 9-1-1 emergency response system call for help if you think you have an emergency.) Air ambulance is also covered, but, only if ground ambulance service can’t provide the service needed. Air ambulance service, if medically necessary, is provided only to  the nearest hospital that can give you the care you need.

• Base charge and mileage
• Disposable supplies
• Monitoring, EKG’s or ECG’s, cardiac defibrillation, CPR, oxygen, and IV Solutions

$100 per trip

Nothing for all other services and supplies

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

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

• Diagnostic evaluation
• Crisis intervention and stabilization for acute episodes
• Medication evaluation and management (pharmacotherapy)
• Psychological and neuropsychological testing necessary to determine the appropriate psychiatric treatment
• Treatment and counseling (including individual or group therapy visits)
• Diagnosis and treatment of substance use disorders, including detoxification, treatment and counseling
• Professional charges for intensive outpatient treatment in a provider's office or other professional setting
• Electroconvulsive therapy
• Behavioral health treatment for pervasive developmental disorder or autism
• Intensive in-home behavioral health services, when available in your area. These services do not require confinement to the home.
• Online visits

Note: For purposes of an individual who presents written documentation of being diagnosed with a maternal mental health condition from the individual's treating healthcare provider, completion of covered services for the maternal mental health condition shall not exceed twelve (12) months from the diagnosis or from the end of pregnancy,  whichever occurs later. A maternal mental health condition is a mental health condition that can impact a woman during pregnancy, peri or postpartum, or that arises during pregnancy, in the peri or postpartum period, up to one year after delivery.

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

$30 per office visit

Individual and group psychotherapy for the treatment of smoking cessation

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

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

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

Before you get services for facility-based care for the treatment of mental or nervous disorders or substance use, you must get our approval first. 

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

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

Not covered:

• Academic or educational testing or counseling.  Remedying an academic or education problem.  Any educational treatment or any services that are educational, vocational, or training in nature except as specifically provided or arranged by us.
• Treatment of any sexual problems unless due to a medical problem, physical defect, or disease.

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

• Drugs and medications which need a prescription by law.  Formulas prescribed by a doctor for the treatment of phenylketonuria.  These formulas are subject to the copay for brand name drugs.
• Growth hormone.
• Insulin, glucagon, and other prescription drugs for the treatment of diabetes
• Syringes for use with insulin and other medications you inject yourself
• Drugs that have FDA labeling to be injected under the skin by you or a family member
• Disposable diabetic supplies (that is, testing strips, lancets, and alcohol swabs)
• Prescription drugs for treatment of impotence and/or sexual dysfunction are limited to organic (non-psychological) causes
• Inhaler spacers and peak flow meters for the treatment of pediatric asthma.  These items are subject to the copay for brand name drugs.
• Off label use of covered drugs if prescribed by a Plan doctor
• Hormone therapy
• Drugs to treat gender dysphoria (Certain hormone therapies may require prior authorization, contact the pharmacy member services phone number on the back of your ID card).

Note:  If your drugstore’s retail price for a drug is less than the copay shown, you will not be required to pay more than that retail price.

Note:  Written prescriptions are valid for 12 months from the date the prescription is written.

Note: A 90-day supply of maintenance drugs can be obtained at a maintenance drugstore. For more details contact the member services number on the back of your identification card.

At Participating Level 1 Pharmacies:
$10 copay for Tier 1 drugs
$50 copay for Tier 2 drugs
$80 copay for Tier 3 drugs
$80 copay for compound medications
$10 copay for diabetic supplies

At Participating Level 2 Pharmacies:
$20 copay for Tier 1 drugs
$60 copay for Tier 2 drugs
$90 copay for Tier 3 drugs
$80 copay for compound medications
$10 copay for diabetic supplies

At Non-Participating Pharmacies:
50% of the prescription drug maximum allowed amount for Tier 1 drugs
50% of the prescription drug maximum allowed amount for Tier 2 drugs
50% of the prescription drug maximum allowed amount for Tier 3 drugs
50% of the prescription drug maximum allowed amount for diabetic supplies

For drugs through the Mail Service Program:
$25 copay for Tier 1 drugs
$110 copay for Tier 2 drugs
$170 copay for tier 3 drugs
$10 copay for diabetic supplies

For drugs through the Specialty Pharmacy Program:
25% of our allowance up to a maximum copay of $200

• Oral anti-cancer medications

25% of our allowance up to a maximum copay of $175

• FDA approved drugs for the treatment of tobacco cessation use.

Note:  This includes prescription and physician prescribed over-the-counter medications.

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

• Contraceptive coverage is available at no cost to FEHB members. The contraceptive benefit includes at least one option in all methods of contraception (as well as the screening, education, counseling, and follow-up care). Any contraceptive that is not already available without cost sharing on the formulary can be accessed through the contraceptive exceptions process as prescribed by an approved provider by calling the RxServices phone number on the back of your card.

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

Not covered:

• Drugs and medications used to induce spontaneous and non-spontaneous abortions
• Professional charges for giving and injecting drugs.  While not covered under this prescription drug benefit, they may be covered as specified in Section 5(a).
• Drugs and medications you can get without a doctor’s prescription, except insulin or niacin for cholesterol lowering
• Drugs labeled “Caution, Limited by Federal Law to Investigational Use,” or Non-FDA approved investigational drugs.  Drugs and medications prescribed for experimental indications.  If you are denied a drug because we determine that the drug is experimental or investigative, you may ask that the denial be reviewed by an external independent medical review organization.
• Drugs which haven’t been approved for general use by the state or Food and Drug Administration (FDA).  This does not apply to drugs that are medically necessary for a covered condition.
• Drugs and medications dispensed or given in an outpatient setting; including, but not limited to inpatient facilities and doctors’ offices.  While not covered under this prescription drug benefit, if you need these drugs, they are covered as specified throughout Section 5.
• Cosmetics, health and beauty aids
• Drugs and medications dispensed by or while you are confined in a hospital, skilled nursing facility, rest home, sanitarium, convalescent hospital or similar facility.  While not covered under this prescription drug benefit, if you need these drugs, they are covered as specified throughout Section 5.
• Drugs used mainly for cosmetic purposes (for example, Retin-A for wrinkles).  But, this will not apply to the use of this type of drug for medically necessary treatment of a medical condition other than one that is cosmetic.
• Drugs used mainly for treating infertility (for example, Clomid, Pergonal, and Metrodin) unless medically necessary for another covered condition
• Drugs for losing weight, except when needed to treat morbid obesity (for example, diet pills and appetite suppressants)
• Drugs you get outside the United States unless related to emergency services or urgent care
• Herbal, nutritional and diet supplements
• Compound medications unless all the ingredients are FDA-approved and require a prescription to dispense, and the compound medication is not essentially the same as an FDA-approved product from a drug manufacturer. Exceptions to non-FDA approved compound ingredients may include multi-source, non-proprietary vehicles and/or pharmaceutical adjuvants. Compound medications must be obtained from a member drugstore. You will have to pay the full cost of the compound medications you get from a non-member drugstore.
• Vitamins, nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them
• Any investigational drugs or devices, non-health services required for you to receive the treatment, the costs of managing the research, or costs that would not be a covered service under this plan for non-Investigative treatments, unless specifically stated.

Preventive care medications

Medications to promote better health as recommended by ACA or with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a healthcare professional and filled by a network pharmacy. These may include some over-the-counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients.  For current recommendations go to www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations.

The following drugs and supplements are covered without cost-share, even if over-the-counter, are prescribed by a healthcare professional and filled at a network pharmacy. The list includes but is not limited to:

• Aspirin (81 mg) for men age 45-79 and women age 55-79  and women of childbearing age
• Folic acid supplements for women of childbearing age  400 & 800 mcg
• Pre-natal vitamins for pregnant women
• Fluoride tablets, solution (not toothpaste, rinses) for children age 0-6

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

Nothing

Preventive drugs for the following conditions:

• Asthma
• Blood clots
• Diabetes
• Heart health and high blood pressure
• High cholesterol
• Osteoporosis
• Stroke

Note: You may obtain a copy of the drug list by calling the customer service number on the back of your identification card or visit the web site at https://www11.anthem.com/pharmacyinformation/.

Nothing

We will cover emergency care for accidental injury to natural teeth. The care is not covered if you hurt your teeth while chewing or biting.

We will also cover medically necessary dental or orthodontic services that are an integral part of reconstructive surgery for cleft palate procedures. “Cleft palate” means a condition that may include cleft palate, cleft lip, or other craniofacial anomalies associated with cleft palate.

Important:  If you decide to receive dental services that are not covered under this plan, a dentist who participates in an Anthem Blue Cross - Select HMO network may charge you their usual and customary rate for those services.  Prior to providing you with dental services that are not a covered benefit, the dentist should provide a treatment plan that includes each anticipated service to be provided and the estimated cost of each service.  If you would like more information about the dental services that are covered under this plan, please call the Customer Service number on your Member ID card.

Not covered: 

• Braces or other appliances or services for straightening the teeth (orthodontic services) except as specifically stated in “Reconstructive Surgery”. 
• Dental devices and oral appliances for snoring.
• Dental treatment, regardless of origin or cause, except as specified below. “Dental treatment” includes but is not limited to preventative care and fluoride treatments; dental x-rays, supplies, appliances, dental implants and all associated expenses; diagnosis and treatment related to the teeth, jawbones or gums, including but not limited to: 
  • Extraction, restoration, and replacement of teeth; 
  • Services to improve dental clinical outcomes.

This exclusion does not apply to the following: 

• Services which we are required by law to cover; 
• Services specified as covered in this booklet;
• Dental services to prepare the mouth for radiation therapy to treat head and/or neck cancer.
  

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 benefit decision under the OPM disputed claim process (see Section 8).

Health concerns don't follow a 9-to-5 weekday schedule. Sometimes you need answers to your health questions right away-and that can be in the middle of the night or while you're away on vacation. That's why the 24/7 NurseLine is there for you and your family 24 hours a day, seven days a week.

You can call the 24/7 NurseLine any time to speak with a registered nurse who is trained to help you make more informed decisions about your health situation.

For accurate, confidential health information, call the number on the back of you member ID card. A nurse is just a phone call away.

Sensitive Topic?

No problem. Not everyone is comfortable discussing their health concerns with someone else. If you prefer, you can call and listen to confidential recorded messages about hundreds of health topics in English and Spanish by accessing the AudioHealth Library. Call the number on the back of you member ID card.

BlueCard® Program

With the BlueCard® Program, Plan members have access to benefits when traveling outside the Plan's service area for urgent care and emergency room services. To find a nearby healthcare provider, members can simply call BlueCard Access at 800-810-BLUE (2583).

Guest Membership Program

We offer guest memberships at affiliated HMO Plans through the Guest Membership Program. Whenever you or a family member is away from our service area for more than 90 days, you may become a guest member at an affiliated HMO near your destination. Reasons to consider a guest membership include extended out-of-town business, children away at school, dependent children in another state, or a winter "snowbird" residency in the South. To determine if a guest membership is available at your destination, call 800-827-6422.

We use the Blue Distinction Center for Transplants as our transplant network. The network consists of leading medical facilities throughout the nation. For a list of transplant hospitals near you, call 800-824-0581.

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.  To obtain claim forms, or for claims questions and assistance, call us at 800-235-8631 or at our website at www.anthem.com/ca.

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:  Anthem Blue Cross, P.O. Box 60007 Los Angeles, CA. 90060-0007.

You normally won’t have to submit claims to us unless you receive prescriptions from a non-participating pharmacy. You need to take a claim form with you to the non-participating pharmacy. If you need a claim form or if you have questions, call us at 800-235-8631 or visit our website at www.anthem.com/ca. Have the pharmacist fill out the form and sign it. Then send the claim form (within 90 days).

Submit your claims to:  Claims Department, P.O. Box 52065, Phoenix, AZ  85072-2065. 

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

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

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

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

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

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

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

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

b) Send your request to us at: Anthem Blue Cross-Select HMO Appeals, 3075 Vandercar Way, Mail Loc. OH3402-B014, Cincinnati, OH  45209; 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 members), 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 stare 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 information so that we receive it within 60 days of our request. We will then decide within 30 more days.

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

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

You must write to OPM within:

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

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, FEHB 2, 1900 E Street, NW, Washington, DC 20415.

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 physician's 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 letter 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 disputed claim with OPM.  Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request.  However, for urgent care claims, a healthcare professional with knowledge of your medical condition may act as your authorized representative without your express consent.

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

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

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

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

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

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

When you have double coverage, one plan normally pays its benefits in full as the primary 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.anthem.com/ca.

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 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.

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

We do not cover services that:

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

You must use our Plan providers.

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

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

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

If another person or entity, through an act or omission, causes you to suffer an injury or illness, and if we pay benefits for that injury or illness, you must agree to the provisions listed below. In addition, if you are injured and no other person or entity is responsible but you receive (or are entitled to) a recovery from another source, and if we provide benefits for that injury, you must agree to the following provisions:

• All recoveries you obtain (whether by lawsuit, settlement, or otherwise), no matter how described or designated, must be used to reimburse us in full for benefits we paid. Our share of any recovery extends only to the amount of benefits we have paid or will pay to you or, if applicable, to your heirs, administrators, successors, or assignees.
• Reimbursement to us out of your recoveries shall take first priority (before any of the rights of any other parties are honored).  Our right of reimbursement is not subject to reduction based on attorney fees or costs under the “common fund” doctrine.  Our right of reimbursement is fully enforceable regardless of whether you are “made whole” (you are fully compensated for the full amount of damages claimed).  We will not reduce our share of any recovery unless we agree in writing to a reduction, because (1) you do not receive the full amount of damages that you claimed, or (2) you had to pay attorneys’ fees.  This is our right of recovery. 
• If you do not seek damages for your illness or injury, you must permit us to initiate recovery on your behalf (including the right to bring suit in your name). This is called subrogation.
• If we pursue a recovery of the benefits we have paid, you must cooperate in doing what is reasonably necessary to assist us. You must not take any action that may prejudice our rights to recover.

You must tell us promptly if you have a claim against another party for a condition that we have paid or may pay benefits for, and you must tell us about any recoveries you obtain, whether in or out of court. We may seek a lien on the proceeds of your claim in order to reimburse ourselves to the full amount of benefits we have paid or will pay.

We may request that you assign to us (1) your right to bring an action or (2) your right to the proceeds of a claim for your illness or injury. We may delay processing of your claims until you provide the assignment.

Note: We will pay the costs of any covered services you receive that are in excess of any recoveries made.

The following are examples of circumstances in which we may subrogate or assert a right of recovery:

• When you or your dependent are injured on premises owned by a third party; or
• When you or your dependent are injured and benefits are available to you or your dependent, under any law or under any type of insurance, including, but not limited to: 
  • Personal injury protection benefits
  • Uninsured and underinsured motorist coverage (does not include no-fault automobile insurance)
  • Workers’ compensation benefits 
  • Medical reimbursement coverage

Contact us if you need more information about subrogation.

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 877-888-3337, TTY 877-889-5680, you will be asked to provide information on your FEHB Plan so that your plans can coordinate benefits. Providing your FEHB information may reduce your out-of-pocket cost.

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

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

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

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

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

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

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

Claims process when you have the Original Medicare Plan – You probably will never have 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 claims will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something about filing your claims, call us at 800-235-8631 or see our website at www.anthem.com/ca.

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

When Medicare Part A is primary – we will waive the Inpatient hospital copayments.

Note: Once you have exhausted your Medicare Part A benefits then you will pay the inpatient hospital copayment.

When Medicare Part B is primary – we will waive copayments and coinsurance for care received from covered professional and facility providers.

Note: We do not waive benefit limitations. In addition, we do not waive any coinsurance or copayments for prescription drugs.

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

Benefit Description: Deductible

High Option You pay  without Medicare: $0
High Option You pay with Medicare Part B: $0

Benefit Description:  Catastrophic Protection Out-of-Pocket Maximum

High Option You pay  without Medicare: $3,000 self only/$6,000 family
High Option You pay with Medicare Part B: $3,000 self only/$6,000 family

Benefit Description: Part B Premium Reimbursement Offered

High Option You pay  without Medicare: N/A
High Option You pay with Medicare Part B: N/A

Benefit Description: Primary Care Physician

High Option You pay  without Medicare: $30
High Option You pay with Medicare Part B: $0

Benefit Description: Specialist

High Option You pay  without Medicare: $40
High Option You pay with Medicare Part B: $0

Benefit Description: Inpatient Hospital

High Option You pay  without Medicare: $250 per day for a maximum of 4 days
High Option You pay with Medicare Part B: $0

Benefit Description: Outpatient Hospital

High Option You pay  without Medicare: $250 per visit for surgical admissions or $40 per visit for other services
High Option You pay with Medicare Part B: $0

Benefit Description: Incentives offered

High Option You pay  without Medicare: N/A
High Option You pay with Medicare Part B: NA

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

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private healthcare choices (like HMOs and regional PPOs) in some areas of the country. To learn more about Medicare Advantage plans, contact Medicare at 800 MEDICARE (800-633-4227), TTY:877-486-2048 or at www.medicare.gov.

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

This Plan and our Medicare Advantage plan:  You may enroll in an Anthem Medicare Advantage plan and also remain enrolled in our FEHB plan. In this case, we will waive any of our copayments or coinsurance for your FEHB coverage.

In the Anthem Medicare Advantage plan we offer benefits, such as wellness programs like SilverSneakers®.

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 or coinsurance. If you enroll in a Medicare Advantage plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

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

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

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

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

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

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

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

• Medicare was the primary payor before eligibility due to ESRD

• Medicare based on age and disability

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

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

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

See Section 4.

See Section 4.

See Section 4.

Custodial care is care for your personal needs. This includes help in walking, bathing or dressing. It also includes preparing food or special diets, feeding, giving medication which you usually do yourself or any other care for which the services of a professional healthcare provider are not needed.

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

Drugs you take on a regular basis to treat or control a chronic illness such as heart disease, high blood pressure, epilepsy, or diabetes. If you are not sure the prescription drug you are taking is a maintenance medication or need to determine if your pharmacy is a maintenance pharmacy, please call Member Services at the number on the back of your Identification Card or check our website for more details.

A member drugstore that is contracted with our pharmacy benefit manager to dispense a 90-day supply of maintenance drugs.

Medically necessary procedures, services, supplies or equipment are those that your medical group or Anthem Blue Cross decides are:

• Appropriate and necessary for the diagnosis or treatment of the medical condition.
• Provided for the diagnosis or direct care and treatment of the medical condition.
•  Within standards of good medical practice within the organized medical community.
• Not primarily for your convenience, or for the convenience of your doctor or another provider.
• Not more costly than an alternative service or sequence of services that is medically appropriate and is likely to produce equivalent therapeutic or diagnostic results in regard to the diagnosis or treatment of the patient’s illness, injury, or condition.
• The most appropriate procedure, supply, equipment or service which can safely be provided.  The most appropriate procedure, supply, equipment or service must satisfy the following requirements:
  • There must be valid scientific evidence demonstrating that the expected health benefits from the procedure, equipment, service or supply are clinically significant and produce a greater likelihood of benefit, without a disproportionately greater risk of harm or complications, for you with the particular medical condition being treated than other possible alternatives; and
  • Generally accepted forms of treatment that are less invasive have been tried and found to be ineffective or are otherwise unsuitable; and
  • For hospital stays, acute care as an inpatient is necessary due to the kind of services you are receiving or the severity of your condition, and safe and adequate care cannot be received by you as an outpatient or in a less intensified medical setting.

Our Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. In most cases, our Plan allowance is equal to a rate we negotiate with providers. This rate is normally lower than what they usually charge and any savings are passed on to you.

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

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

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

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

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

If you believe your claim qualifies as an urgent care claim, please contact our Customer Service Department at 800-235-8631.  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.

PCP office visit copay: $30 or Specialist office visit copay: $40

28

$250 per day for a maximum of 4 days.

48

Nothing unless surgery is performed. $250 per outpatient surgery admission.

49

$150 per visit

54

$250 per day for a maximum of 4 days 

56

Regular cost-sharing

56

Network: Level 1 at Participating Pharmacies

$10 copay for Tier 1 Drugs

$50 copay for Tier 2 drugs

$80 copay for Tier 3 drugs

Network: Level 2 at Participating Pharmacies

$20 copay for Tier 1 drugs

$60 copay for Tier 2 drugs

$90 copay for Tier 3 drugs

$80 for compound medications; 25% of our allowance up to a maximum of $200 or 25% of our allowance up to a maximum of $175 for oral anti-cancer  Tier 4 drugs. 

Non-Network pharmacy: 50% of drug maximum allowed amount for Tier 1; 50% of drug maximum allowed amount for Tier 2; 50% of drug maximum allowed amount for Tier 3

62

$25 for Tier 1; $110 for Tier 2; $170 for Tier 3 and $10 for diabetic supplies.

62

 Nothing

66

Annual eye refraction; you pay nothing.

34

24/7 Nurse Line

67

Nothing after $3,000/Self Only or $3,000 per person/Self Plus One or $6,000/Self and Family per year

23