• No pre-existing condition limitation

Minimum essential coverage (MEC)

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

Minimum value standard

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

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

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

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

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

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

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

• Types of coverage available for you and your family

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

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

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

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

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

Family member coverage

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

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

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

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

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

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

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

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

• Children’s Equity Act

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

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

• If you have no FEHB coverage, your employing office will enroll you 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.

• When benefits and premiums start

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2021 benefits of your prior plan or option. If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option.  However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2020 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

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

• When you retire

• When FEHB coverage ends

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

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

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

• Upon divorce

If you are divorced from a Federal employee, or annuitant, you may not continue to get benefits under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get 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.

• Temporary Continuation of Coverage (TCC)

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

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

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

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

• Converting to individual coverage

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

• Your coverage under TCC or the spouse equity law ends (If you canceled 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, 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 800-446-4674 or visit our website at wwww.priorityhealth.com/fehb.

Health Insurance Marketplace

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

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 participating Plan provider, or fill a prescription at a participating 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 800 446-5674 or write to us at: Priority Health, 1231 East Beltline NE, Grand Rapids, MI  49525.  You may also request replacement cards through our website: www.priorityhealth.com.

Where you get covered care

You get care from “Plan providers” and “Plan facilities.” You will only pay copayments, deductibles, and/or coinsurance. Our Open Access program allows you to receive covered services from a participating Plan provider without a required referral from your Primary care physician (PCP) or another Plan provider in the network.  You may also seek covered care from a Retail Health Clinic located anywhere within the United States.  You do not need a referral to even though we have not contracted with the treating providers, which means they are non-participating providers.  The prior approval waiver applies to non-participating providers at Retail Health Clinics, emergency rooms and urgent care centers only. 

Plan providers

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

Each member must designate one of our Plan providers as his or her Primary care physician (PCP).  Each family member may select his or her own in-network Primary care physician. A PCP may refer a member to another participating Plan provider when it would be more appropriate for him or her to receive care from a different type of health professional or Specialist.  Members may also choose to seek care from any in-network Specialist without a PCP referral.  

We list Plan providers in our Provider Directory, which we update periodically. Members can access our Provider Directory by using our online Find A Doctor tool at www.priorityhealth.com.  This tool makes it easy for members to search for health care providers and facilities nationwide. Members enter plan type and location, and can search by Primary care physician, hospital, pharmacy and other facility/service. The tool provides members with:

• Provider name
• Gender
• Network status
• Distance
• Address
• Office hours
• Map

For Lansing area providers, members have in network access through Sparrow Physicians Health Network. A complete listing of these providers can be found at www.sparrow.org/SPHN.

In addition to the online tool,  a member can call our customer service department at 800 446-5674 and a representative will help him or her find a doctor or facility.

Plan facilities

Plan facilities and hospitals are located throughout Michigan.  Priority Health contracts with these facilities to provide covered services to our members.  We list these in the Provider Directory and update the information periodically.  

As stated under Plan Providers above, members can search for plan facilities by accessing our online Find A Doctor tool at www.priorityhealth.com.  This tool makes it easy for members to search for health care providers and facilities nationwide. In addition to the online tool,  a member can call our customer service department at 800 446-5674 and a representative will help him or her find a doctor or facility.

For Lansing area facilities, members have in network access through Sparrow Physicians Health Network. A complete listing of these providers can be found at www.sparrow.org/SPHN.

Retail Health Clinics are a category of walk-in clinics located in retail stores, supermarkets and pharmacies within the United States.  Providers at these locations treat uncomplicated minor illnesses and may provide some preventive care services.  We have not contracted with the providers for these services, so even though the care is covered under this plan, and the Retail Health Clinic may be located within a participating Plan pharmacy, the providers are considered non-participating or non-Plan providers.  However, you do not need a referral from your PCP, another Plan provider or Priority Health before you seek covered services from a Retail Health Clinic. 

Even though these providers are considered non-participating, you do not need a referral from your PCP, another Plan provider or Priority Health before you seek covered services from a Retail Health Clinic. Evaluation and Management services will be covered, and you will only be responsible for any applicable deductible, copayments or coinsurance amounts explained in Section 5 of this Brochure.

What you must do to get covered care

We require your PCP and other Plan providers to discuss all treatment options available to you whether the treatment or services are covered or not covered.  Providers are not expected to know when services have limitations or are excluded from coverage.  The Brochure provides you with this information.  

Your PCP or other health professionals may recommend, and you may choose, treatment options even if they are not covered or are limited by this Plan.  You are required to pay for any services you receive that are not covered or that exceed your maximum benefit. 

Primary care

Your PCP provides your primary health care, orders lab tests and x-rays, prescribes medication or therapies and arranges hospitalization when necessary.  Your PCP may be a family practitioner, a general practitioner, an internal medicine specialist, a pediatrician, an obstetrician/gynecologist, a nurse practitioner or a physician assistant. Each family member may select his or her own in-network Primary care physician.  

If you do not select a PCP, we will assign one to you. You can change your PCP at any time, including one assigned to you, except while you are in the hospital.  You may also change the PCP of a minor or covered dependent who is incapable of choosing a PCP. All changes are effective on the first day of the month after we receive your request unless you are changing a child’s pediatrician.  Pediatrician changes are effective immediately.

You may choose to seek services from a Plan provider without referral from your PCP at any time.  For example, a woman can see a participating Plan obstetrician/gynecologist without referral from her PCP.  However, we recommend you talk with your PCP about any issues concerning your medical care, and contact him or her before you receive medical services, except in a medical emergency.  Working with your PCP improves the coordination and continuity of care you receive.  When necessary, your PCP will work with other participating Plan providers and Specialist providers to ensure you receive the care you need.

We recommend you receive a physical examination from your PCP within one year of joining Priority Health.

Specialty Care

Specialty care is care provided by a health professional or physician other than your PCP.  This care may be provided by both Plan providers and non-network providers.  Plan providers are those listed in our Provider Directory.  

You do not need a referral from your PCP or Priority Health to see a Plan provider for most covered service.  Only certain services, when provided by your PCP or a Plan provider require prior approval.  Additional information about prior approval requirements is included below.  

Non-Network Providers

You do not need a referral from your PCP or Priority Health to seek covered services from a Cigna Network Provider outside the services area (but within the United States) if you are a Covered Dependent child residing outside the Service Area.  Prior Approval requirements are described under Other Services below. 

You do not need prior approval or a referral from your PCP or Priority Health to seek covered services from a Retail Health Clinic located within the United States. 

All other covered services you receive from non-network providers must be prior approved by us.  If the standard of care (medically appropriate treatment) for your condition is not available from a Plan provider, your PCP may ask Priority Health for approval to refer you to a non-network provider. If you do not receive approval from Priority Health prior to seeking covered services from a non-network provider, or if we determine the medically appropriate treatment for your condition is available from a Plan provider, you will be responsible for payment.  A referral from your PCP or another Plan provider is not enough if you want the services to be covered.  If Priority Health approves the referral, we will notify your PCP or the Plan provider who makes the request. 

 A Second Medical Opinion

It is often appropriate to ask for a second medical opinion before receiving certain treatments for health conditions and before many proposed surgeries.  You may request a second medical opinion from a Plan specialist who has skills and training substantially similar to those of the physician making the original treatment recommendation without prior approval.  If there are no Plan providers with the skills and training needed to provide a second opinion on the proposed treatment, we may cover a second medical opinion from a non-network specialist.  Prior approval from Priority Health is required before the second opinion is obtained.  Any tests, procedures, treatments or surgeries recommended by the consulting provider must be performed by a Plan provider unless we approve the services in advance.

Occasionally, Priority Health may require that you get a second opinion from a Plan specialist that we have chosen.  This second medical opinion is used to assist us in determining whether services or supplies are medically/clinically necessary according to our medical and behavioral health policies or adopted criteria.

Termination of Provider's Participation

Plan providers contract with us to provide covered services to members.  Either the Plan provider or Priority Health can terminate that contract at any time.  We cannot guarantee that you will be able to receive services from a specific Plan provider while you are covered under this Plan.  We will notify you if your PCP is no longer a Plan provider so you can select another PCP.  If your specialist terminates his or her participation with Priority Health, you can contact your PCP for a recommendation of a new specialist to visit.  Our Customer Service department is also available to assist you in finding another Plan provider and in receiving care during the transition to a new provider.  If you have any questions, please call our Customer Service department. 

If you are being treated by a participating Plan provider whose contract with us is terminated, you may be allowed to continue seeing that provider for a limited time.  So long as the provider is able to continue treating you, you can receive covered services if, at the time of the provider’s contract termination:

1. you are receiving on-going care.  You may continue to see this provider for up to 90 days or until Priority Health makes other arrangements for you to receive the same services from another Plan provider. 
2. you are undergoing treatment for a chronic or disabling condition, or are in the second or third trimester of pregnancy.  You may continue to see this provider for up to 90 days, or through completion of postpartum care. 
3. you are undergoing treatment for a terminal Illness.  You may continue to be treated by this provider for the remainder of your life. 

If the Plan provider’s contract with Priority Health has been terminated for quality of care reasons, we will not cover any care you receive from him or her.

You may also be able to continue seeing your specialist for up to 90 days after you receive a notice of change if you have a chronic and disabling condition and will lose access to your specialist because we:

1. terminate our contract with your specialist for reasons other than for cause;
2. drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB program plan; or
3. reduce our services area and you enroll in another FEHB plan.  

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

Hospital care

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

If you are hospitalized when your enrollment begins

We pay for covered services from the effective date of your enrollment.  However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 800 446-5674.  If you are new to the FEHB Program, we will arrange for you to receive care and reimburse you for your covered expenses 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, only care shown under Other Services requires prior approval by Priority Health in order to be covered under this Plan.  If you do not get prior approval for the other services, you will be responsible.  For a more detailed list of care that requires prior approval, call our Customer Service department or go to our website priorityhealth.com.  This list may change periodically as new technology and standards of care emerge. 

Inpatient hospital admission

Prior approval is required before all inpatient hospital admissions, including those for mental health and substance use. We will evaluate the medical necessity of your proposed stay and the number of days required to treat your condition, in order to make our decision.  

You do not need prior approval from your PCP or Priority Health to seek care, from a Retail Health Clinic within the United States, in a medical emergency or when urgent care is needed.  Additionally, inpatient hospital stays for a mother and her newborn of up to 48 hours following a vaginal delivery and 96 hours following a cesarean section do not require prior approval.  However, we encourage you to notify us at least 60 days before your due date so we are better prepared to assist you at that time.

Other services

You do not need prior approval from either your PCP or us for most services.  For certain services, however, your treating physician must obtain prior approval from us, including any services he or she is recommending you obtain from a non-network provider.  Before giving approval, we will consider if the service is covered, medically/clinically necessary and follows generally accepted medical practice.  If coverage for services from a non-network provider is being requested, we also determine if the medically appropriate care is available from a Plan provider.  Below are some of the services and supplies that require prior approval by Priority Health:

• Referrals to non-network providers
• Transplants and evaluation for transplants
• Outpatient services
• Intensive outpatient treatment services for substance use
• Non-hospital facility services (including skilled nursing facility care)
• Radiology examinations
• High-tech radiology examinations, including but not limited to:
  • positron-emission tomography (PET) scans 
  • magnetic resonance imaging (MRI) 
  • computed tomography (CT scans) 
  • nuclear cardiology studies.
• Reconstructive surgeries, including: 
  • Paniculectomy 
  • Rhinoplasty 
  • Septorhinoplasty
• Bariatric Surgery
• Durable medical equipment (DME) charges over $1,000 and all rentals
  
• Prosthetics and orthotics charges over $1,000 and all shoe inserts
• Simulators
• Selected injectable drugs
• Home health care, including home infusion services and intermittent skilled services 
• Supplemental feedings administered via tube or IV
• Genetic testing
• Clinical trials and any services considered experimental, investigational or unproven 
• Comprehensive pain and headache programs
• Growth Hormone Treatment

How to request prior approval for an inpatient admission or for other services

To obtain prior approval, you or your provider must call the applicable number below:

• for mental health or substance use services – 800 673-8043
• for any other covered services that require approval – 800 828-8302.

Non-urgent care claims

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

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

Urgent care claims

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

If you fail to provide sufficient information, we will contact you within 24 hours after we receive the claim to let you know what information we need to complete our review of the claim.  You will then have up to 48 hours to provide 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 800 446-5674.  You may also call OPM’s Health Insurance 3 at 202 606-0755 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 800 446-5674. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

Concurrent care claims

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

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

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 notify us within 48 hours or as soon as reasonably possible following the day of the emergency admission, even if you have been discharged from the hospital. 

Maternity care

Inpatient hospital stays for a mother and her newborn of up to 48 hours following a vaginal delivery and 96 hours following a cesarean section do not require prior approval.  However, we encourage you to notify us at least 60 days before your due date so we are better prepared to assist you at that time.

If delivery occurs in the hospital, The Hospital length of stay for the mother or newborn begins at the time of delivery (or in the case of multiple births, at the time of the last delivery).   If delivery occurs outside a hospital, the hospital length of stay begins at the time the mother or newborn is admitted as a hospital inpatient in connection with childbirth.  The determination  of whether an admission is in connection with childbirth is a medical decision to be made by the attending provider.

Note: When a newborn requires definitive treatment during or after the mother’s confinement, the newborn is considered a patient in his or her own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.  Newborns must be added to the plan within 30 days to obtain coverage.

If your treatment needs to be extended

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

The Federal Flexible Spending Account Program - FSAFEDS

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

It is important to get prior approval so you know ahead of time if the services or supplies you seek will be covered.  If the required prior approval is not obtained, we may review the claim after you receive the services.  If we determine that the care received was medically/clinically necessary and provided by a non-network provider, the care may only be covered if the necessary care is unavailable from a Plan provider.  If we determine that the care received was not medically/clinically necessary or the care was provided by a non-network provider when it could have been provided by a Plan provider, the services will not be covered.

Circumstances beyond our control

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

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

To reconsider a
non-urgent care claim

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

In the case of a pre-service claim and unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request.

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

2. Ask you or your provider for more information.

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

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

3. Write to you and maintain our denial.

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

Cost-sharing is the general term used to refer to any of your out-of-pocket costs for the covered services you receive, such as deductible, coinsurance, and copayments.

Copayments

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

Example: When you see your Primary care physician, under the High Option you pay a copayment of $10 per office visit. When you see your Primary care physician under the Standard Option, you pay a copayment of $15 per office visit.  When you see your Primary care physician under the Value Option, you pay a copayment of $10 per office visit.

Deductible

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

• The calendar year deductible is $0 Self Only, Self Plus One and Self and Family enrollment under the High Option.  Under a Self Only, Self Plus One or Self and Family enrollment there is no deductible, and benefits are payable for you on the first date of coverage under High Option.  
• The calendar year deductible is $350 Self Only enrollment and $700 for Self Plus One or Self and Family enrollment (not to exceed the Self Only deductible per person) under the Standard Option.  Under a Self Only enrollment, the deductible is considered satisfied and benefits are payable for you when your covered expense applied to the calendar year deductible for your enrollment reach $350 under the Standard Option.  Under a Self Plus One enrollment or a Self and Family enrollment, the deductible is considered satisfied and benefits are payable for you and other eligible family members when the combined covered expenses applied to the calendar year deductible for your enrollment reach $700 (not to exceed the individual deductible per person) under Standard Option. 
• The calendar year deductible is $1,500 Self Only enrollment and $3,000 for Self Plus One or Self and Family enrollment (not to exceed the Self Only deductible per person) under the Value Option.  Under a Self Only enrollment, the deductible is considered satisfied and benefits are payable for you when your covered expense applied to the calendar year deductible for your enrollment reach $1,300 under the Value Option.  Under a Self Plus One enrollment or a Self and Family enrollment, the deductible is considered satisfied and benefits are payable for you and other eligible family members when the combined covered expenses applied to the calendar year deductible for your enrollment reach $3,000 (not to exceed the individual deductible per person) under Value Option. 

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

Coinsurance

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

Example: In our Plan, you pay 50% of our allowance for infertility drugs and durable medical equipment.  

Your catastrophic protection out-of-pocket maximum

For the High, Standard and Value Options, after your out-of-pocket expenses, including any applicable deductibles, copayments and coinsurance total $7,350 Self Only, or $14,700 for a Self Plus One or Self and Family enrollment in any calendar year you do not have to pay any more for covered services.  The maximum annual limitation on cost sharing listed under Self Only, $7,350, applies to each individual, regardless of whether the individual is enrolled in Self Only, Self Plus One, or Self and Family.

Example: Your plan has a $7,350 Self Only maximum out-of-pocket limit and a $14,700 Self Plus One, or Self and Family out-of-pocket limit.  If you or one of your eligible family members has out-of-pocket qualified medical expense of $7,350 or more for the calendar year, any remaining qualified medical expenses for that individual will be covered fully by your health plan.  With a Self Plus One or Self and Family out-of-pocket maximum of $7,350, a second family member, will continue to accrue out-of-pocket qualified medical expenses up to a maximum of $14,700 for the calendar year before their qualified medical expenses will begin to be covered in full.

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

Carryover

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

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

High Option 

The High Option offers a high level of comprehensive benefits.  This option will cost slightly more than the Standard Option in premiums, but will offer a higher level of benefits.  The High Option includes, but is not limited to, the following:

• No deductible
• 10% coinsurance for all inpatient and outpatient labs and x-rays
• $10 copayment for non-preventive Primary care physician visits
• $35 copayment for Specialist office visits
• $15 Generic/ $50 Preferred brand / $80 Non-preferred brand copayment for prescription drugs
• 20% coinsurance for Preferred Specialty drugs ($150 limit for 31-day supply)
• 20% coinsurance for Non-preferred Specialty drugs ($300 limit for 31-day supply)

Standard Option

The Standard Option offers the same high level of service that comes with the High Option. This option has slightly lesser benefits, but will cost you less in premiums. The Standard Option includes the following differences:

• $350 Self Only and $700 for Self Plus One or Self and Family deductible
• 20% coinsurance for hospital services
• $15 copayment for Primary Care physician visits
• $45 copayment for Specialists office visits
• $20 Generic/ $60 Brand / $90 Non-preferred Brand copayment for prescription drugs
• 20% coinsurance for Preferred Specialty drugs ($200 limit for 31-day supply)
• 20% coinsurance for Non-preferred Specialty drugs ($400 limit for 31-day supply)

Value Option

The Value Option offers the same high level of service that comes with the High and Standard Options. This option has slightly lesser benefits, but will cost you less in premiums. The Value Option includes the following differences:

• $1,500 Self Only and $3,000 for Self Plus One or Self and Family deductible
• 10% coinsurance for hospital services
• $10 copayment for Primary Care physician visits
• $35 copayment for Specialists office visits
• $20 Generic/ $60 Brand / $90 Non-preferred Brand copayment for prescription drugs
• 20% coinsurance for Preferred Specialty drugs ($200 limit for 31-day supply)
• 20% coinsurance for Non-preferred Specialty drugs ($400 limit for 31-day supply)

PriorityWell - Wellness Reward - Subscribers and Spouses only

Earn a $50 gift card to use towards qualified medical expenses between January 1^st and December 31^st by logging in to your Priority Health account and completing your health risk assessment. Instructions on how to complete your health risk assessment are listed below:

Step 1 – Login to your Priority Health account

Step 2 – Click on Health Living

Step 3 – Click on Wellbeing Hub and select Go There

Step 4 – In the banner in green, select get started under the heading health assessment

Your gift card will be sent to you via mail within 5-7 business days from date of completion.

No Referrals

You don’t need a referral from your Primary care physician to see an in-network Specialist.

Worldwide Emergency and Urgent Care

No matter where you travel, we provide worldwide emergency and urgent care

Virtual Visit Services

See a doctor 24/7 from home at no charge to you
Get treated online or over the phone

If you're sick and your doctor isn't available, you don't need to go to the urgent care or emergency room. All Priority Health members can see a doctor 24 hours a day, seven days a week online or over the phone by logging into their member center at priorityhealth.com.

Remember! Your Primary care physician is always the first person you should call when you're sick. He/she knows you and your health, so he/she is the best place to go for routine care, preventive checkups and chronic condition management. He/she may also have options for you to get care quickly, even when their office is closed.

Get care anytime, anywhere with e-visits

e-visits are a great option if you're:
Considering the ER or urgent care for a nonemergency  In need of care outside your doctor's normal business hours, including nights, weekends or holidays or traveling.

What does e-visit care treat?
eCare visits treats non-emergency conditions, such as:
Cold and flu
Fever
Respiratory infections
Sinus infections
Sore throats

See more about e-visits on priorityhealth.com

Assist America provides global emergency medical services for you and your dependents. If someone becomes ill or injured while traveling more than 100 miles from home or is in a foreign country, Assist America provides support with medical referrals, monitoring, evacuation, repatriation and much more.

Assist America features & advantages
- Free to FEHB Priority Health members
- Covers the costs of all services related to getting quality emergency medical care while traveling, such as medical referrals, critical care monitoring, emergency evacuation and other support measures 
- Note: Once a qualified doctor or hospital begins care, all treatment costs are subject to the coverage rules of your plan
- Available everywhere in the world, regardless of geography or political climate
- Access to multilingual, medically-trained employees anytime, anywhere
- Pre-trip information including visa requirements, immunization regulations and security advisories
- No financial cap on services
- No exclusions for pre-existing conditions or extreme sports/hazardous hobbies

Print a reference card to carry when you travel
Get help when you need it by calling Assist America 24 hours a day, 7 days a week, using the contact information and Priority Health reference number on your card. 

Assist America contacts:

800.872.1414 (inside the US)
609.986.1234 (outside the US)
Email: medservices@assistamerica.com
Mobile app: Available for Android and iPhone devices
Website: assistamerica.com

Retail Health Clinic

Retail Health Clinics are a category of walk-in clinics that are located in retail stores, supermarkets and pharmacies.  The centers teat uncomplicated, minor illnesses and provide some preventive health care services.

Evaluation and management services are covered at Retail Health Clinics with the applicable Specialist copayment for contracted facilities.

Cost Estimator

With the Cost Estimator tool, you can see your estimated out-of-pocket costs based on your health plan and deductible, and you can choose a lower-cost option to save money on high-quality care.

Active and Fit

The Active&Fit Direct program allows you to choose from 9,000+ participating fitness centers nationwide for $25 a month (plus a $25 enrollment fee and applicable taxes).

The program offers:

• Online directory maps and locator for fitness centers (available on any device)
• A free guest pass to try out a fitness center before enrolling (where available)
• The option to switch fitness centers to make sure you find the right fit
• Online fitness tracking from a wide variety of popular wearable fitness devices, apps, and exercise equipment
• Visit https://www.activeandfitdirect.com/ to search a location near you

Care Management

As an FEHB member, you have a Dedicated Care Manager who can help you in the following ways:

• Learn and manage your conditions like asthma, hypertension and diabetes
• Connect with resources to help you be your healthiest
• Find an in network doctor or Specialist
• navigate the health care system and coordinate your care

Call the number on the back of your card to be transferred to your Dedicated Care Manager.

Priority Health Member Account

Your Priority Health member account gives you access to your health information in one convenient place.  From renewing prescriptions to scheduling a telehealth visit and even checking the price of health care services before you get care, your Priority Health account puts you in control of your health.

Set up your Priority Health account today.

• Download the Priority Health app from the App Store or Google Play, or visit member.priorityhealth.com.

• Click Sign up and follow the instructions

To ensure the highest level of security for our members, Priority Health uses and authentication and fraud prevention service that validates a member's identify in real time, reducing the risk of identity impersonation.  Priority Health does not use or store this information.

Medication therapy management

Medication therapy management (MTM) is prescription management for members with chronic conditions.

For members dealing with multiple chronic conditions, an annual medication review is just as important as a yearly physical.  Qualified members receive a free 30 minute face to face visit with a pharmacist to review their medications and simplify their regimen, keeping them healthy, productive and on the job. 

During the MTM consultation, the pharmacist will:

• Review all medications and if applicable, help simplify the member's medication regimen
• Recommend alternative drugs to relive any side effects
• Resolve concerns that a member has about their medications, including working with their doctor to make changes to help them feel better
• Provide education on how to take drugs, so members get the best results
• Offer suggestions, such as generic alternatives, that can save money
• Support medication adherence for those not taking their medicine and help remove barriers
• Create a master list of all medications that a member can share with their doctor during appointments

Call the number on the back of your card for further information.

Medical and hospital benefits

In most cases, providers and facilities file claims for you. Providers must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-92 form. For claims questions and assistance, please contact us at 800 446-5674 or visit our website at priorityhealth.com.

When you must file a claim – such as for services you received outside the Plan’s service area – submit it on the HCFA-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:

Priority Health
P.O. Box 232
Grand Rapids, MI 49501-0232

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.

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

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

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

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

b) Send your request to us at: Priority Health, Customer Service Department, MS 1145, P.O. Box 269, Grand Rapids, MI 49501-0269, or send us a secure email from Priority Health Mailbox in your MyHealth Message Center on our website at at priorityhealth.com

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

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

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

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

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

a) Pay the claim or  

b) Write to you and maintain our denial or

c) Ask you or your provider for more information

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

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

3

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

You must write to OPM within:

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

Write OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, FEHB 3, 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 physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
• Copies of all letters you sent to us about the claim;
• Copies of all letters we sent to you about the claim; and
• Your daytime phone number and the best time to call.
• Your email address, if you would like to receive OPM’s decision via email. Please note that by providing your email address, you may receive OPM’s decision more quickly.

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

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

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

4

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

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

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

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

Note:  If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call us at 800 446-5674. We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal. You may call OPM’s Health Insurance, FEHB 3 division at (202) 606-0737 between 8 a.m. and 5 p.m. Eastern Time.

Please remember that we do not make decisions about plan eligibility issues. For example, we do not determine whether you or a dependent is covered under this plan. You must raise eligibility issues with your Agency personnel/payroll office if you are an employee, your retirement system if you are an annuitant or the Office of Workers’ Compensation Programs if you are receiving Workers’ Compensation benefits.

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

When you have double coverage, one plan normally pays its benefits in full as the primary 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, contact Priority Health Customer Service at 800-446-5674.

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

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

Workers’ Compensation

We do not cover services that:

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

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

Medicaid

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

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

When other Government agencies are responsible for your care

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

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

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

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

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

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

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

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

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

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

When you have Medicare

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

The Original Medicare Plan (Part A or Part B)

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

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

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

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

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

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. You will not need to do anything. To find out if you need to do something to file your claim, call us at 800 446-5674 or see our website at priorityhealth.com.

We waive some costs if the Original Medicare Plan is your primary payor.  We will waive some out-of-pocket costs, for the subscriber and spouse, if you purchase Medicare Part B. 

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

Please review the following table as it illustrates your cost share if you are enrolled  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 Part B: $0.00
Standard Option You pay without Medicare Part B:$350 Self Only $700 Self Plus One and Self and Family
Value Option you pay without Medicare Part B: $1,500 Self Only $3,000 Self Plus One and Self and Family
You pay with Medicare Part B: $0.00

Benefit Description: Primary Care Physician
High Option You pay without Medicare Part B: $10.00
Standard Option You pay without Medicare Part B: $15.00  
Value Option you pay without Medicare Part B: $10.00
You pay with Medicare Part B: $0.00

Benefit Description: Specialist
High Option You pay without Medicare Part B: $35.00
Standard Option You pay without Medicare Part B: $45.00  
Value Option you pay without Medicare Part B: $35.00
You pay with Medicare Part B: $0.00

Benefit Description: Inpatient Hospital
High Option You pay without Medicare Part B: $0.00
Standard Option You pay without Medicare Part B:20%
Value Option you pay without Medicare Part B: $10%
You pay with Medicare Part B: $0.00

Benefit Description: Outpatient Hospital
High Option You pay without Medicare Part B: $0.00
Standard Option You pay without Medicare Part B:20%
Value Option you pay without Medicare Part B: $10%
You pay with Medicare Part B: $0.00

Benefit Description: Emergency Care
High Option You pay without Medicare Part B: $200.00
Standard Option You pay without Medicare Part B: $200.00  
Value Option you pay without Medicare Part B:   $200.00
You pay with Medicare Part B: $0.00

Benefit Description: Ambulance Services
High Option You pay without Medicare Part B: $150.00
Standard Option You pay without Medicare Part B: $150.00  
Value Option you pay without Medicare Part B:   $150.00
You pay with Medicare Part B: $0.00

Benefit Description: Urgent Care
High Option You pay without Medicare Part B: $75.00
Standard Option You pay without Medicare Part B: $75.00  
Value Option you pay without Medicare Part B:   $75.00
You pay with Medicare Part B: $0.00

Benefit Description: Durable Medical Equipment / Prosthetics & Orthotic
High Option You pay without Medicare Part B: 50%
Standard Option You pay without Medicare Part B: 50% 
Value Option you pay without Medicare Part B:   50%
You pay with Medicare Part B: $0.00

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

Medicare Advantage (Part C)

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private health care choices (like HMOs and regional PPOs) in some areas of the country. To learn more about Medicare Advantage plans, contact Medicare at 1-800-MEDICARE (1-800-633-4227), (TTY: 1-877-486-2048) or at www.medicare.gov.

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

This Plan and our Medicare Advantage plan: You may enroll in one of the Medicare Advantage plans offered by Priority Health and also remain enrolled in our FEHB plan. We will still provide benefits when your Medicare Advantage plan is primary, even if you are out of the Medicare Advantage plan’s network and/or service area (if you use the providers who participate with this Plan).  However, we will not waive any of our copayments, coinsurance, or deductibles. If you enroll in our 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.

This Plan and another plan’s Medicare Advantage plan: You may enroll in another plan’s Medicare Advantage plan and also remain enrolled in our FEHB plan. We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s network and/or service area (if you use our Plan providers).  However, we will not waive any of our copayments, coinsurance, or deductibles. If you enroll in a Medicare Advantage plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

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

Medicare prescription drug coverage (Part D)

Applied Behavior Analysis (ABA)

Outpatient treatment involving behavioral modification techniques in which reinforcement, either positive or negative, is used to encourage or reduce certain behaviors.  The treatment is delivered in a highly structured and intensive program with one-to-one instruction by a certified therapist.  Prior authorization is required.

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

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

Coinsurance

See Section 4, page 25.

Copayments

See Section 4, page 25.

Cost-sharing

See Section 4, page 25.

Deductible

See Section 4, page 26.

Hospital

An appropriately licensed acute care institution (including a long-term acute care facility) that provides inpatient and outpatient medical care and treatment for ill and injured persons through medical, diagnostic, and major surgical facilities. All services must be provided on its premises under the supervision of a staff of physicians and with 24 hour-a-day nursing and physician service.

Medically/clinically necessary

The services or supplies needed to diagnose or treat your physical or mental condition.  Whether services or supplies are medically/clinically necessary is determined in accordance with Priority Health’s medical and behavioral health policies or adopted criteria that have been approved by community physicians and other providers.  The determination is made by Priority Health’s medical director, or anyone acting at the medical director’s direction, in consultation with other physicians. medical/clinical necessity of mental health and substance use services is determined by our Behavioral Health Department.  In order to be considered Medically/Clinically Necessary, the services or supplies must: (a) be widely accepted as effective; (b) be appropriate for the condition or diagnosis; (c) be essential, based upon nationally accepted evidence-based standards; and (d) cost no more than a treatment that is likely to yield a comparable health outcome.

The determination of whether proposed care is a Covered Service is independent of, and should not be confused with, the determination of whether proposed care is Medically/Clinically Necessary.

Acute Inpatient Hospitalization. This is the most intensive level of care. Prior approval from our Behavioral Health department is required for inpatient services except in a medical emergency. Upon discharge, you will be referred to a less intensive level of care.

Residential Treatment. This is 24-hour confinement in a subacute residential setting (as defined above) licensed by the state with structured, licensed health care professionals accessible 24 hours a day and 7 days a week. A licensed foster-care facility serving as your residence is not Covered and does not meet the definition of “Residential Treatment”. Prior approval from our Behavioral Health department is required for residential treatment services.

Partial Hospitalization. This is a non-residential level of service that is similar in intensity to acute inpatient hospitalization. You are generally in treatment for more than four hours but less than eight hours daily. Prior approval from our Behavioral Health department is required for partial hospitalization services.

Intensive Outpatient Treatment. This is outpatient treatment that is provided with more frequency and intensity than routine outpatient treatment. You are generally in treatment for up to four hours per day, and up to five days per week. You may be treated individually, as a family or in a group.

Outpatient Treatment. This is the least intensive, and most common, type of service. It is provided in an office setting, generally from 45-50 minutes (for individuals) to 90 minutes (for group therapies) per day by a licensed behavioral health professional

The physicians, health professionals, hospitals and other providers and facilities that have not contracted with Priority Health to provide covered services to members. Non-participating or non-Plan providers are not listed in the Priority Health Provider Directory.  covered services and supplies you seek from a non-Plan provider are not covered except as otherwise stated in this brochure.  

Out-of-pocket limit or maximum

The maximum amount of deductibles, copayments and coinsurance you will pay for covered services in a contract year.  Once you reach this overall maximum, covered services will be covered at 100% with no cost to you unless we tell you otherwise in this brochure.  This protects you against catastrophic costs.  Some costs do not count toward this protection.

Plan or participating provider

The physicians, health professionals, hospitals and other facilities that have contracted with Priority Health to provide covered services.  The Providers that make up our network are considered Plan or participating providers and are listed in our Provider Directory.  Most Plan or participating providers offer services within Priority Health's service area.  However, if you are a covered dependent child residing outside the service area, covered services received outside the service area but within the United States are also available from Cigna, a Priority Health leased network provider.  

Primary Care Physician (“PCP”)

The Plan provider you select as explained in Section 3.  Your PCP provides, arranges and coordinates all aspects of your health care to help you receive the right care, in the right place, at the right time.

A licensed health professional or facility that provides health care services.

Reimbursement

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

Retail Health Clinic

Substance Use

Inpatient Detoxification. These are detoxification services that are provided while you are an inpatient in a hospital or subacute unit. When provided in a medical setting, services are managed jointly by our Behavioral Health and Health Management Departments.

Medically Monitored Intensive Inpatient Treatment. Following full or partial recovery from acute detoxification symptoms, this type of care is provided at an inpatient facility or subacute unit.

Residential Treatment. This is 24-hour confinement in a subacute residential setting (as defined above) licensed by the state with structured, licensed health care professionals accessible 24 hours a day and 7 days a week. A licensed foster-care facility serving as your residence is not covered and does not meet the definition of “residential treatment”. Prior approval from our Behavioral Health department is required for residential treatment services.

Partial Hospitalization. This is an intensive, non-residential level of service provided in a structured setting, similar in intensity to inpatient treatment. You are generally in treatment for more than four hours but generally less than eight hours daily.

Intensive Outpatient Programs. These are outpatient services provided by a variety of health professionals at a frequency of up to four hours daily, and up to five days per week.

Outpatient Treatment. This is the least intensive level of service. It is provided in an office setting generally from 45-50 minutes (for individuals) to 90 minutes (for group therapies) per day.

Outpatient/Ambulatory Detoxification. These detoxification services may be provided on an outpatient basis within a structured program when the consequences of withdrawal are non-life-threatening. These services are covered under your medical benefits.

Subscriber

An FEHB Employee or FEHB Annuitant.

Urgent care or urgent care center

Care provided at an urgent care center, instead of a hospital emergency room, when you need immediate care to treat a non-life threatening illness or injury to limit severity and prevent complications.  

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-serve 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 800 446-5674. You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

Medical services provided by physicians: 

Diagnostic and treatment services provided in the office

$10 copayment Primary care physician; $35 copayment Specialist

31 -55

Services provided by a hospital:

Inpatient

10% coinsurance for all inpatient and outpatient labs and x-rays

55-60

Services provided by a hospital:  Outpatient

10% coinsurance for all inpatient and outpatient labs and x-rays

56-57

Urgent Care: In-area

$75 copayment

59-60

Urgent Care:  Out-of-area

$75 copayment

59-60

Emergency benefits: In-area

$200 copayment per visit, waived if admitted

59-60

 Emergency benefits: Out-of-area

$200 copayment per visit, waived if admitted

59-60

Mental health and substance use disorder treatment:

Regular cost-sharing

61-64

Prescription drugs:

Retail / 30-day supply: $15 copayment per Generic prescription, $50 copayment per Brand prescription, $80 copayment per Non-preferred Brand

Preferred Specialty: 20% coinsurance up to a maximum of $150 per fill / Non-preferred Specialty: 20% coinsurance up to a maximum of $300 per fill.

Mail Order / 90 day-supply: 2x copayment

65-70

Dental care:

No coverage unless in accidental injury for repair of sound natural teeth.

71

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

$7,350 Self Only / $14,700 Self Plus One and Self and Family

14

Medical services provided by physicians:

Diagnostic and treatment services provided in the office

$15 copayment Primary care physician; $45 copayment Specialist 

31 -54

Services provided by a hospital:

• Inpatient*

20% coinsurance

55-56

• Outpatient*

20% coinsurance

56-57

Urgent Care:

• In-area

$75 copayment

59-60

• Out-of-area

$75 copayment

59-60

Emergency benefits:

• In-area*

$200 per visit, waived if admitted

59-60

• Out-of-area*

$200 per visit, waived if admitted

59-60

Mental health and substance use disorder treatment:

Regular cost-sharing

61-64

Prescription drugs:

Retail / 30-day supply: $20 copayment per Generic prescription, $60 copayment per Brand prescription, $90 copayment for Non-preferred prescription

Preferred Specialty: 20% coinsurance up to a maximum of $200 per fill / Non-preferred Specialty: 20% coinsurance up to a maximum of $400 per fill.

Mail Order / 90-day supply: 2x copayment 

65-70

Dental care:

No coverage unless in accidental injury for repair of sound natural teeth.

71

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

$7,350 Self Only / $14,700 Self Plus One and Self and Family

14

Medical services provided by physicians:

Diagnostic and treatment services provided in the office

Office visit copay: $10 copayment Primary care physician; $35 copayment Specialist*

31 -54

Services provided by a hospital:

• Inpatient*

10% coinsurance

55-56

• Outpatient*

10% coinsurance

56-57

Urgent Care:

• In-area*

$75 copayment

59-60

• Out-of-area*

$75 copayment

59-60

Emergency benefits:

• In-area*

$200 copayment per visit, waived if admitted

59-60

• Out-of-area*

$200 copayment per visit, waived if admitted

59-60

Mental health and substance use disorder treatment:

Regular cost-sharing

61-64

Prescription Drugs:

Retail / 30-day supply: $20 copayment per Generic prescription, $60 copayment per Brand prescription, $90 copayment for Non-preferred Prescription

Preferred Specialty: 20% coinsurance up to a maximum of $200 per fill / Non-preferred Specialty: 20% coinsurance up to a maximum of $400 per fill.

Mail Order / 90-day supply: 2x copayment 

65-70

Dental care:

No coverage unless in accidental injury for repair of sound natural teeth.

71

Vision care:

No coverage for routine eye exam

None

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

$7,350 Self Only / $14,700 Self Plus One and Self and Family

14