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

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

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

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

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

• When you may change your enrollment
• How you can cover your family members
• What happens when you transfer to another Federal agency, go on leave without pay, enter military service, or retire
• 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 members. Family members include your spouse and your dependent children under age 26, including any foster children authorized for coverage by your employing agency or retirement office. Under certain circumstances, you may also continue coverage for a disabled child 26 years of age or older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event. The Self Plus One or Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member.  When you change to Self Plus One or Self 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.

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

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

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

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

Family members covered under your Self and Family enrollment are your spouse (including your spouse by a valid common-law marriage from a state that recognizes common-law marriages) and children as described in the chart below.  A Self Plus One enrollment covers you and your spouse, or one 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 2024 benefits of your prior plan or option. If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option.  However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2023 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

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

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.

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

If you were married to an enrollee and your divorce or annulment is final, you may not remain covered as a family member under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage 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 https://www.opm.gov/healthcare-insurance/life-events/memy-family/im-separated-or-im-getting-divorced/#url=Health. We may request that you verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

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

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

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

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

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

• Your coverage under TCC or the spouse equity law ends (If you 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 www.priorityhealth.com/fehb.

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.

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 Provider (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. 

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, copayment, co-insurance) contact your Carrier to enforce the terms of its provider contract.

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

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

Each member must designate one of our Plan providers as his or her Primary Care Provider (PCP).  Each family member may select his or her own in-network Primary Care Provider. 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 healthcare providers and facilities nationwide. Members enter plan type and location, and can search by Primary Care Provider, hospital, pharmacy and other facility/service. The tool provides members with:

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

This plan recognized that transgender, non-binary, and other gender diverse members require health are 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 at 800-446-5674 or priorityhealth.com for assistance.

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 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 healthcare 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.

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, copayment, co-insurance) contact your Carrier to enforce the terms of its provider contract.

We require your Primary Care Provider 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 Primary Care Provider 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. 

Your Primary Care Provider (PCP) provides your primary healthcare, orders lab tests and x-rays, prescribes medication or therapies and arranges hospitalization when necessary.  Your Primary Care Provider 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 Provider.  

If you do not select a Primary Care Provider, we will assign one to you. You can change your Primary Care Provider at any time, including one assigned to you, except while you are in the hospital.  You may also change the Primary Care Provider of a minor or covered dependent who is incapable of choosing a Primary Care Provider. 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 Primary Care Provider at any time.  For example, a woman can see a participating Plan obstetrician/gynecologist without referral from her Primary Care Provider.  However, we recommend you talk with your Primary Care Provider 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 Primary Care Provider improves the coordination and continuity of care you receive.  When necessary, your Primary Care Provider 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 Primary Care Provider within one year of joining Priority Health.

Specialty care is care provided by a health professional or physician other than your Primary Care Provider.  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 Primary Care Provider or Priority Health to see a Plan provider for most covered service.  Only certain services, when provided by your Primary Care Provider 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 Primary Care Provider 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 Primary Care Provider 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 Primary Care Provider 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 Primary Care Provider 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 Primary Care Provider 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 Primary Care Provider is no longer a Plan provider so you can select another Primary Care Provider.  If your specialist terminates his or her participation with Priority Health, you can contact your Primary Care Provider 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.  

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

We pay for covered services from the effective date of your enrollment.  However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 800 446-5674.  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 Provider 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. 

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.

You do not need prior approval from either your Primary Care Provider 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
• 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 healthcare, 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

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.

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 800 446-5674.  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).

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. 

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

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 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.

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.

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.  If your claim is in reference to a contraceptive, call 800-446-5674.

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 unless we request additional information, we will notify you of our decision within 72 hours after receipt of your reconsideration request.

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

2. Ask you or your provider for more information.

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

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

3. Write to you and maintain our denial.

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.

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

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

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 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.  

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.

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.

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.

The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” for out-of-network emergency services; out-of-network non-emergency services provided with respect to a visit to a participating health care facility; and out-of-network air ambulance services.

A surprise bill is an unexpected bill you receive for

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

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

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

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.priorityhealth.com/fehb or contact the health plan at 1-800-446-5674.

The link to our plan website with surprise billing information in plain language on https://www.priorityhealth.com/landing/surprise-billing:

1. the restrictions on balance billing in certain circumstances,
2. any applicable state law protections against balance billing,
3. the requirements described under Code section 9816, ERISA section 716, and PHS Act section 2799A-1, and
4. information on contacting appropriate state and federal agencies in the case that an individual believes that a provider or facility has violated the restrictions against balance billing.

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

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 Provider 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)

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 Provider 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)

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 Provider 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)

Professional services of physicians

• In physician's office
• Telephonic visits
• Through secure electronic portal

$10 copayment per Primary Care Provider visit

$35 copayment per Specialist visit

$15 copayment per Primary Care Provider visit

$45 copayment per Specialist visit

$10 copayment per Primary Care Provider visit

$35 copayment per Specialist visit, deductible applies to specialist visit

Professional services of physicians

• During an inpatient or outpatient hospital stay
• At an ambulatory surgery center
• At Home
• Advance care planning

No charge

20% coinsurance

Deductible applies

10% coinsurance

Deductible applies

2nd MD

This benefit allows for an external third-party review of a member’s treatment plan by a leading expert outside of Priority Health called 2nd MD we you can obtain an independent expert and unbiased second opinion with nationwide leading specialists. You may qualify for this service if you have received a new, eligible diagnosis or are scheduled for an eligible procedure of surgery. If you qualifies, 2nd MD will reach out directly. You may also be referred by a Priority Health care manager. Eligible procedures were selected based on the high cost and high volume. Below are procedures and surgeries eligible for review by 2nd MD:

Musculoskeletal:

• Ankle/Foot Fusion
• Ankle/Foot Injection
• Ankle/Foot Repair/Reconstruction
• Hip Arthroscopy
• Hip Injection
• Hip/Knee Replacement
• Shoulder Arthroscopy
• Shoulder Replacement
• Spinal Fusion
• Spinal Injection
• Spinal Laminectomy/Laminotomy/Decompression
• Spine Replacement/Device

Cardiac:

• Ablation

Gastrointestinal:

• Hernia Repair
• Laparoscopy Colectomy
• Lap Hernia Repair

Women’s Health:

• Hysterectomy
• Laparoscopy Hysterectomy

No charge

No charge

No charge

Retail Health Clinics

(A category of walk in clinics located in retail stores, supermarkets and pharmacies within the United States that treat uncomplicated minor illnesses and provide some preventive health care services.)

$35 copayment per visit for evaluation and management services only

$45 copayment per visit for evaluation and management services only

Deductible does not apply

$35 copayment per visit for evaluation and management services only

Deductible does apply

Telehealth Visits - Medical

Virtual (video) visits and e-visits are available 24/7.  To schedule a telehealth visit, please schedule your visit through your member center at www.priorityhealth.com.

No charge

No charge

No charge

Teletherapy Visits - Behavioral Health

Virtual (video) visits are available 24/7.  To schedule a teletherapy visit, please schedule your visit through your member center at www.priorityhealth.com.

No charge

No charge

No charge

Test (in a non-hospital facility or physician's office) such as:

• Blood tests
• Urinalysis
• Non-routine pap tests
• Pathology
• X-rays
• Non-routine mammograms
• Ultrasound
• Electrocardiogram and EEG

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

Appropriate office visit copayment (Primary Care Provider or Specialist) may apply for office services

20% coinsurance

Deductible applies

Appropriate office visit copayment (Primary Care Provider or Specialist) may apply for office services

10% coinsurance

Deductible applies

Appropriate office visit copayment (Primary Care Provider or Specialist) may apply for office services

Advanced Diagnostic Imaging Services (Such as CT, MRI, MRA, Nuclear Cardiology studies, PET scan)

Note:  Prior approval required for certain radiology examinations.  For additional information, see Other services under You need prior Plan approval for certain services in Section 3.

$150 copayment (copayment waived if performed while confined in a hospital as an inpatient)

Maximum 10 copayments per individual per contract year

$150 copayment (copayment waived if performed while confined in a hospital as an inpatient)

Deductible applies

Maximum 10 copayments per individual per contract year

$150 copayment (copayment waived if performed while confined in a hospital as an inpatient)

Deductible applies

Maximum 10 copayments per individual per contract year

Not covered

Services related to dental care are excluded

All charges

Routine physical every year Individual counseling on prevention and reducing health risks

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

• Immunizations such as Pneumococcal, influenza, shingles, tetanus/Tdap, and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/
• Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
• Individual counseling on prevention and reducing health risks
• Preventive care benefits for women such as Pap smears, gonorrhea prophylactic 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 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 covered every calendar year
• Medical Nutrition Therapy and Intensive Behavioral Therapy for the prevention of obesity related comorbidities as recommended under the U.S. Preventive Services Task Force (USPSTF) A and B recommendations.
• Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule

No charge

No charge

No charge

Not covered:

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

All charges

All charges

All charges

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.

All charges

All charges

All charges

• 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/Tdap, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/index.html
• You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations

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.

No charge

No charge

No charge

Complete maternity (obstetrical) care, such as:

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

Notes:

• Routine prenatal visits, gestational diabetes screening, and postnatal visits are covered under the "Preventive Care" category above.
• Attendance at an approved maternity education program is Covered at no charge.  
• Visits and consultations for complications of pregnancy are covered as described under the "Diagnostic and treatment services" category above.
• See Section 5(c) "Services provided by a hospital or other facility, and ambulance services" for Coverage related to maternity services, including delivery and nursery services.
• Any facility or physician fees for non-maternity care will be covered at the appropriate benefit level. 
• You do not need precertification of a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section, then your physician or the hospital must contact us for precertification of additional days. Further, if your baby stays after you are discharged, your physician or the hospital must contact us for precertification of additional days for your baby.
• When a newborn requires definitive treatment during or after the mother’s hospital stay, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

No charge

No charge

Deductible does not apply

No charge

Deductible does not apply

No charge

No charge

Deductible does not apply

No charge

Deductible does not apply

A range of voluntary family planning services, limited to:

• Voluntary sterilization (See Surgical procedures Section 5 (b)
• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo Provera)
• Intrauterine devices (IUDs)
• Diaphragms

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

$10 copayment for Primary Care Provider office and $35 copayment when performed in Specialist office.

No charge for physician services when performed in an inpatient or outpatient facility in connection with other covered inpatient or outpatient surgery.   

No charge for outpatient and inpatient facility charges only when in connection with other covered inpatient and outpatient surgery.  

$15 copayment for Primary Care Provider office and $45 copayment when performed in Specialist office. Deductible does not apply.

20% coinsurance for physician services when performed in an inpatient or outpatient facility in connection with other covered inpatient or outpatient surgery.  Deductible applies. 

20% coinsurance for outpatient and inpatient facility charges only when in connection with other covered inpatient and outpatient surgery.  Deductible applies.

$10 copayment for Primary Care Provider office and $35 copayment when performed in Specialist office.  Deductible does not apply.

10% coinsurance for physician services when performed in an inpatient or outpatient facility in connection with other covered inpatient or outpatient surgery.  Deductible applies. 

10% coinsurance for outpatient and inpatient facility charges only when in connection with other covered inpatient and outpatient surgery.  Deductible applies.

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic testing and counseling

All charges

All charges

All charges

Diagnosis and treatment of infertility specific to:

• Treatment of the underlying cause infertility
• Artificial insemination:  
  • Intravaginal insemination (IVI)
  • Intracervical insemination (ICI)
  • Intrauterine insemination (IUI)
  • In vitro fertilization (IVF)
• Fertility drugs (see note below) 
  • We cover Injectable fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit
• Prior authorization does not apply
• If you leave the FEHB plan prior to completion of services, any costs incurred for applicable services currently in progress will become the responsibility of you as the member
• Please see section 10 for the definition of infertility which states The inability to conceive a successful pregnancy after 12 months of egg-sperm contact if the individual is under the age of 35 or after 6 months if the individual is age 35 and older. Infertility may also be justified based on the individual having a medical or other recognized condition as a cause of infertility.

See Infertility medical policies at https://www.priorityhealth.com/provider/manual/medical-policies#letter-i

50% coinsurance

50% coinsurance

Deductible of $350 self only and $700 self plus one and self and family applies to inpatient/outpatient facility and does not apply to services rendered in the physician (specialist) office.

50% coinsurance

Deductible of $1500 self only and $3000 self plus one and self and family applies to inpatient/outpatient facility and services rendered in the physician (specialist) office.

Iatrogenic Infertility (Fertility Preservation):

• This benefit does not require preauthorization. 
• Covered services include:
  • Sperm count, freezing, thawing, and storage
  • Egg freezing, thawing and storage (Iatrogenic Preservation egg storage has no time limit)
• Members who leave Priority Health prior to the completion of these services will be responsible for any costs incurred for applicable services received after their enrollment has been terminated, including continued storage. The Carrier defines infertility as the Definition of Infertility is the inability to achieve a successful pregnancy after 12 months or more of unprotected intercourse or after 6 months if the female partner is over the age 35.

See Infertility medical policies at https://www.priorityhealth.com/provider/manual/medical-policies#letter-i

50% coinsurance

50% coinsurance

Deductible of $350 self only and $700 self plus one and self and family applies to inpatient/outpatient facility and does not apply to services rendered in the physician (specialist) office.

50% coinsurance

Deductible of $1500 self only and $3000 self plus one and self and family applies to inpatient/outpatient facility and services rendered in the physician (specialist) office.

Not covered:

• Assisted reproductive technology (ART) procedures, such as embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)
• Charges for assisted reproduction or artificial conception services performed while not a member of this plan.
• Services performed prior to meeting the definition of Infertility as described.
• Services performed if the individual on whom the procedure is being performed is not an eligible member, including but not limited to donor charges, fees, and services; services associated with donor sperm and donor oocytes, infertility services and fees rendered to a surrogate.

All charges

All charges

All charges

Testing and treatment

Allergy injections

Allergy serum

No charge

No charge

Deductible does not apply

No charge

For testing, office visit copayment may apply

Deductible does apply

Not covered: 

• Provocative food testing 
• Sublingual allergy desensitization

All charges

All charges

All charges

• Chemotherapy and radiation therapy
  • Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue  Transplants on page 57.
• Respiratory and inhalation therapy
• Dialysis – hemodialysis and peritoneal dialysis
• Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy
• Growth hormone treatment is covered under the prescription drug benefit as a preferred and non-preferred specialty benefit.
  • Requires prior authorization prior to any coverage.
    • If approved, members would need to fill with our specialty pharmacy Accredo.
  • Link to the prior authorization forms https://www.priorityhealth.com/drug-authorization-forms-list. Reference forms under “Human Growth Hormone”.  The names of the growth hormone drugs are listed on the form.
  • Review drug names to verify coverage on our approved drug list https://www.priorityhealth.com/formulary.  
  • We only cover GHT when we preauthorize the treatment. We will ask you to submit information that establishes that the GHT is medically necessary.  Ask us to authorize GHT before you begin treatment.  We will only cover GHT services and related services and supplies that we determine are medically necessary.  See Other services under You need prior Plan approval for certain services in section 3.

No charge

20% coinsurance

Deductible applies

20% coinsurance

Deductible applies

60 visits per condition, (combined for Physical, Occupational, and Speech Therapies and/or Chiropractic care)

60 visits per condition - cardiac rehabilitation combined with pulmonary rehabilitation

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.

$10 copayment per visit

$15 copayment per visit

Deductible does not apply

$10 copayment per visit

Deductible applies

Not covered:

• Long-term rehabilitative therapy
• Exercise programs
• Cognitive Therapy

All charges

All charges

All charges

60 visits per condition, (combined for Physical, Occupational, and Speech Therapies and/or Chiropractic care)

Treatment of Autism Spectrum Disorder is listed under the Autism Spectrum Disorder services section

$10 copayment per visit

$15 copayment per visit

Deductible does not apply

$10 copayment per visit

Deductible applies

Physical, occupational, and speech therapy

$10 copayment per visit

$15 copayment per visit

Deductible does not apply

$10 copayment per visit

Deductible applies

Applied Behavioral Analysis (ABA)

Note: Prior authorization is required

Note: Physical, occupational, and speech therapy and Applied Behavioral Analysis (ABA) coverage for treatment of Autism Spectrum Disorder is available for children and adolescents through under age 19.  Multiple copayments may apply during one day of service.

$10 copayment per visit

$15 copayment per visit

Deductible does not apply

$10 copayment per visit

Deductible applies

No charge

No charge

No charge

Not covered: 

• Services and supplies related to hearing care, including ear plugs, external BAHA devices, hearing aids and adjustments
• Examinations for hearing aids, including examinations performed during a covered hearing screening

All charges

All charges

All charges

One preventive vision screening, performed as part of a physical exam, during each calendar year to determine vision loss for all ages, including children.

No charge 

No charge

No charge

Not covered:

• Eyeglasses, eyeglass frames, all types of contact lenses or corrective lenses
• Eye exercises, visual training, orthoptics, sensory integration therapy
• Radial keratotomy, laser surgeries and other refractive keratoplasties
• Refractions (tests to determine if eyeglasses are needed, and if so, what prescription)
• All other vision care services 

All charges

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

$10 copayment per office visit to your Primary Care Provider

$35 copayment per office visit to a Specialist

$15 copayment per office visit to your Primary Care Provider

$45 copayment per office visit to a Specialist

Deductible does not apply

$10 copayment per office visit to your Primary Care Provider

$35 copayment per office visit to a Specialist

Deductible applies

Not covered:

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

All charges

All charges

All charges

Artificial limbs and eyes

Prosthetic sleeve or sock

Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

Corrective orthopedic devices for the non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy.

Prior Approval required for devices over $1,000

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

50% coinsurance

50% coinsurance

Deductible applies

50% coinsurance

Deductible applies

All orthotics with the exception of foot orthotics

Prior Approval required for devices over $1,000

50% coinsurance

50% coinsurance

Deductible applies

50% coinsurance

Deductible applies

Not covered:

• Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Cochlear and other hearing implants 

All charges

All charges

Diabetes Supplies furnished by a participating durable medical equipment provider are covered at 100%. Please see a list below of those supplies covered:

• Blood Glucose Monitors
• Syringes, lancets and blood glucose test strips
• Insulin Pumps
• Shoe inserts for members with diabetic neuropathy
• Special Shoes prescribed for a person with diabetes when medically/clinically necessary

No charge

No charge

No charge

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

• Oxygen
• Hospital beds
• Wheelchairs
• Crutches
• Walkers
• Motorized wheelchairs when medically necessary

Prior Approval required for devices over $1,000

50% coinsurance

50% coinsurance

Deductible applies

50% coinsurance

Deductible applies

Medical Foods

Supplemental feedings administered via tube.  This type of nutrition therapy is also known as enteral feeding.  Formulas intended for this type of feeding as well as supplies, equipment, and accessories needed to administer this type of nutrition therapy are covered.

Supplemental feedings administered via an IV.  This type of nutrition therapy is also known as parenteral nutrition.  Nutrients, supplies and equipment needed to administer this type of nutrition are covered.

Oral nutritional formula for Inborn Errors of Metabolism (IEM is a covered benefit when all of the following are met:

The formula is a medical food labeled and used for the dietary management of an IEM that interferes with the metabolism of specific nutrients (e.g. PKU), Homocystinuria, Maple Syrup Urine Disease), and

Nutrition is ordered and managed by a team consisting of a board-certified clinical or medical biochemical geneticist and a metabolic dietician, and

The following limits and exclusions apply:

Formula that meets the criteria in the above is covered at the DME/Supplies benefit level as defined in coverage documents.

Formulas, food products, and supplements that do not require a physician’s order are not a covered benefit (e.g. grocery products for a low-protein diet).

When criteria 1 and 2 above are met, coverage for IEM formula is not limited by age, weight, or lab values.

50% coinsurance

50% coinsurance

Deductible applies

50% coinsurance

Deductible applies

Not covered:

• Luxury or deluxe items, such as bath tub seats, reachers, raised toilet seats, vehicle modifications
• Devices, braces used to affect performance in sport related activities
  • Duplicate Equipment
  • Items not medical in nature
  • Comfort/Convenience items such as power carts, bed boards, bathtub lifts, air conditioners, batteries, over the bed tables, home modifications
  • Disposable supplies i.e. sheets, gloves, diapers and bags
  • Exercise and hygienic equipment i.e. exercycles, bidets, toilet and bathtub/shower seats
  • Self-help devices not primarily medical in nature such as sauna baths, elevators and ramps, special telephone, computer or other electronic communication devices.
  • Implantable pumps
  • Experimental or research equipment
  • Devices/braces used specifically as safety items
  • Outpatient medical supplies including, but not limited to gauzes, tapes, and elastic bandages
  • Earplugs

All charges

Intermittent skilled services furnished in the home by a physical therapist, occupational therapist, respiratory therapist, speech therapist, licensed practical nurse or registered nurse.

Prior Approval required except for Hospice Care services in the home

No charge

Not covered:

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

All charges

All charges

60 visits per condition, (combined for Physical, Occupational, and Speech Therapies and/or Chiropractic care)

$10 copayment per visit

$15 copayment per visit

Deductible does not apply

$10 copayment per visit

Deductible applies

Not covered:

All charges

All charges

All charges

Not covered:

Acupuncture and Non-traditional services, including but not limited to:

All charges

Care manager assistance

Tobacco Cessation programs, including individual/group/telephone counseling, over the counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence.

Diabetes self management for pre-diabetes

Livongo - self diabetes management for members over the age of 18 with type 2 diabetes. 

• Eligible members will receive information from Livongo and Priority Health. Members may be encouraged to participate in Livongo when speaking to a care manager or provider. Members will be contacted via email or direct mail by Livongo informing them of their eligibility in the program. Members may also hear about the program through communications from Priority Health.
• Eligible members who enroll will receive a welcome kit that includes:
  • Cellular-enabled blood glucose monitor
  • Lancing device and lancets
  • Blood glucose test strips
  • Two blood glucose control solution droppers
  • AC adapter and USB Charger
  • Getting Started Guide
  • Carrying Case

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

No charge

A comprehensive range of services provided during an inpatient hospital stay, outpatient hospital visit or at an ambulatory surgery center, including:

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

No charge

20% coinsurance when provided during an inpatient hospital stay, outpatient hospital visit or at an ambulatory surgery center

Deductible applies

10% coinsurance when provided during an inpatient hospital stay, outpatient hospital visit or at an ambulatory surgery center

Deductible applies

Certain Surgeries and Treatments (Physician fees only)

• Bariatric Surgery
• Reconstructive surgery
  • Blepharoplasty of upper lids
  • Breast reduction
  • Panniculectomy
  • Rhinoplasty
  • Septorhinoplasty
  • Surgical treatment of male gynecomastia
• Skin disorder treatments
  • Scar revisions
  • Keloid scar treatment
  • Treatment of hyperhidrosis
  • Excision of lipomas
  • Excision of seborrheic keratosis
  • Excision of skin tags
  • Treatment of vitiligo
  • Port wine stain and hemangioma treatment
• Varicose veins treatments
• Sleep apnea treatment procedures

Prior Approval required for bariatric surgery,panniculectomy, rhinoplasty and septorhinoplasty.  Bariatric surgery is covered when medically/clinically necessary. 

No charge

20% coinsurance

Deductible applies

10% coinsurance

Deductible applies

Not covered:

• Reversal of voluntary sterilization
• Cosmetic surgery
• Routine treatment of conditions of the foot; see Foot care

All charges

All charges

All charges

Reconstructive surgery to correct congenital birth defects and/or effects of illness or injury if:

The defects and/or effects of Illness or Injury cause clinical functional impairment.  "Clinical functional impairment" exists when the defects and/or effects of Illness or Injury:

• causes significant disability or major psychological trauma (psychological reasons do not represent a medical or surgical necessity unless you are undergoing psychotherapy for issues solely related to the Illness or Injury for which the reconstructive surgery is requested),
• interfere with employment or regular attendance at school,
• require surgery that is a component of a program of reconstructive surgery for a congenital deformity or trauma, or
• contribute to a major health problem, and

We reasonably expect the surgery to correct the condition, and

The services are approved in advance by us and you receive them within two years of the event that caused the impairment, unless either of the following applies:

• The impairment caused by Illness or Injury was not recognized at the time of the event.  In that case, treatment must begin within two years of the time that the problem is identified, or
• Your treatment needs to be delayed because of developmental reasons.

We will cover treatment to correct the functional impairment even if the treatment needs to be performed in stages as long as that treatment begins within two years of the event causing the impairment and as long as you remain a member.   

Gender Affirming Care Services (GACS), including pre- and post-surgical hormone therapy, is considered medically necessary when ALL of the following criteria are met: 

1. age 18 or older, AND
2. diagnosis of gender incongruence/dysphoria made by licensed practitioner with expertise in gender dysphoria, incongruence, and diversity, AND
3. capacity to make a fully informed decision and to consent for treatment, AND
4. acknowledge aftercare requirements and importance of pre- and postoperative aftercare requirements, AND
5. gender affirming surgical procedure is completed by surgeon with training and active practice in gender-affirming surgical procedures

Surgical treatment for gender affirmation is considered medically necessary once criteria is met for procedures including but not limited to:   

• Breast surgery
• Facial gender affirming surgeries
• Genital Reconstructive surgery
• Gonadectomy (Hysterectomy and salpingo-oophorectomy in female-to-male and orchiectomy in male-to-female patients)

 Please see the Priority Health Gender Affirming Surgery Medical Policy on our website at: https://www.priorityhealth.com/provider/manual/medical-policies#letter-g for additional details.

No charge

20% coinsurance when provided during an inpatient hospital stay, outpatient hospital visit or at an ambulatory surgery center

Deductible applies

10% coinsurance when provided during an inpatient hospital stay, outpatient hospital visit or at an ambulatory surgery center

Deductible applies

• Reconstruction of the breast on which a mastectomy was performed;
• Surgery and reconstruction of the other breast to produce a symmetrical appearance; and
• Prostheses and treatment of physical complications at all stages of the mastectomy, including lymphedema.

The requirement to receive services within two years of the event that caused the impairment does not apply to reconstructive surgery following breast cancer.

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

No charge

20% coinsurance for services provided during an inpatient hospital stay, outpatient hospital visit or at an ambulatory surgery center

Deductible applies

10% coinsurance for services provided during an inpatient hospital stay, outpatient hospital visit or at an ambulatory surgery center

Deductible applies

Not covered:

Cosmetic services, prescription drugs, treatment, therapies or procedures done primarily to improve the way any part of the body looks or functions unless medically necessary for gender affirming care (this list may not be all-inclusive):

• Blepharoplasty, brow reduction, brow lift, lower lids
• Breast enlargement procedures, including augmentation mammoplasty, implants, and silicone injections of the breast, augmentation except when provided as post-mastectomy reconstructive services
• Chemical peel for acne
• Chin augmentation (reshaping or enhancing the size of the chin), nose, cheek implants
• Collagen implants
• Diastasis recti repair
• Excision or repair of excess or sagging skin, however, a panniculectomy is Covered according to our medical policies.
• Face lift, forehead lift
• Fat grafts, unless an integral part of another Covered procedure
• Forehead augmentation
• Gluteal and hip augmentation
• Hair reconstruction (transplantation or removal)
• Hair transplants or repair of any congenital or acquired hair loss, including hair analysis
• Jaw/mandibular reduction or augmentation
• Lip reduction or enhancement
• Liposuction (unless an integral part of another Covered procedure), lipofilling
• Mastopexy
• Nipple/areola reconstruction
• Orthodontic treatment, even when provided along with reconstructive surgery
• Pectoral implants
• Removal for excessive hair growth by any method, even if caused by an underlying medical condition
• Reversal of gender affirming surgery
• Rhinophyma treatment
• Rhytidectomy (wrinkle removal)
• Salabrasion
• Skin resurfacing (e.g. dermabrasion, chemical peel)
• Spider vein removal
• Tattoo removal
• Voice modification surgery

All charges

All charges

All charges

Oral surgical procedures, limited to:

• Treatment of fractures of the jaws or facial bones
• Rebuilding or repair of soft tissues of the mouth or lip needed to correct anatomical functional impairment caused by congenital birth defect or accidental injury, including correction of cleft lip, cleft palate
• Removal of stones from salivary ducts
• Excision of leukoplakia or malignancies
• Biopsy and removal of tumors or cysts of the jaw, other facial bones, soft tissues of the mouth, lip, tongue, accessory sinuses, and salivary glands and ducts and incision of abscesses when done as independent procedures
• Surgical services required to correct accidental Injuries, including emergency care to stabilize dental structures following Injury to sound natural teeth
• Treatment of oral and/or facial cancer
• Other surgical procedures that do not involve the teeth or their supporting structures

No charge for services provided during an inpatient hospital stay, outpatient hospital visit or at an ambulatory surgery center.

$15 copayment for services provided in a Specialist office

20% coinsurance for services provided during an inpatient hospital stay, outpatient hospital visit or at an ambulatory surgery center, deductible applies

$45 copayment if services provided in a Specialist office

10% coinsurance for services provided during an inpatient hospital stay, outpatient hospital visit or at an ambulatory surgery center, deductible applies

$35 copayment if services provided in a Specialist office, deductible applies

"Temporomandibular Joint Syndrome" or "TMJ" means muscle tension and spasms related to the temporomandibular joint, facial, and cervical muscles, causing pain, loss of function and neurological dysfunction. 

The following care for TMJ Syndrome is covered:

• Medical care or services to treat dysfunction or TMJS resulting from a medical cause or Injury. 
• Office visits for medical evaluation and treatment. 
• X-rays of the temporomandibular joint including contrast studies, but not dental x-rays.
• Myofunctional therapy.
• Surgery to the temporomandibular joint, such as condylectomy, meniscectomy, arthrotomy, and arthrocentesis.

50% coinsurance

Deductible applies

50% coinsurance

Deductible applies

Orthognathic Surgery

This includes surgical treatment to restructure the bones or the other parts of the jaw to correct a congenital birth defect, the effect of an Illness or Injury or to correct other functional impairments.    

We will only Cover the following surgery services:

1. Referral care for evaluation and orthognathic treatment.
2. Cephalometric study and x-rays.
3. Orthognathic surgery and post-operative care, including hospitalization, if necessary.

50% coinsurance

50% coinsurance

Deductible applies

50% coinsurance

Deductible applies

Not covered:

• Oral implants and transplants
• Dental surgery in preparation for implants or dentures
• Procedures that involve the teeth or their supporting structures including (such as the periodontal membrane, gingiva, and alveolar bone) including dentingious and odontogenic cysts.
• Bite splints, orthodontic treatment, or other dental services to treat TMJ Syndrome
• Orthodontic treatment, even when provided along with oral or orthognathic surgery
  

All charges

All charges

All charges

These solid organ transplants are covered. Solid organ transplants are limited to: These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. See other services under You need prior Plan approval for certain services on page 22.

Solid Organ and Tissues Transplants: Subject to Medical Necessity

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

Blood or Marrow Stem Cell Transplants: Not subject to medical necessity. Plan’s denial is limited to indicators for transplant such as refractory or relapsed disease, cytogenetics, subtype, or the diagnosis.

Allogeneic transplants for:

• Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia 
• Hodgkin’s lymphoma – relapsed 
• Non-Hodgkin’s lymphoma – relapsed
• Acute myeloid leukemia 
• Myeloproliferative Disorders (MPDs)– MD Review
• Chronic lymphocytic leukemia/small lymphocytic leukemia (CLL/SLL)
• Hematopoietic stem cell
• Hemoglobinopathy  MD REVIEW
• Marrow Failure and Related Disorders (i.e., Fanconi’s, PNH, Pure Red Cell Aplasia)
• Myelodysplasia/Myelodysplastic Syndromes
• Paroxysmal Nocturnal Hemoglobinuria  MD REVIEW
• Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)
• Severe combined immunodeficiency
• Severe or very severe aplastic anemia
• Sickle cell anemia
• X-linked lymphoproliferative syndrome

Autologous transplants for:

• Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
• Hodgkin's lymphoma – relapsed
• Non-Hodgkin's lymphoma – relapsed
• Amyloidosis
• Neuroblastoma

Blood or Marrow Stem Cell Transplants: Not Subject to Medical Necessity

Allogeneic transplants 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. May Be Limited to Clinical Trials.

Autologous transplants for:

• Childhood rhabdomyosarcoma   MD REVIEW
• 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) 
• Advanced Childhood kidney cancers  

Mini-transplants performed in a Clinical Trial Setting (nonmyeloablative, reduced intensity conditioning for with a diagnosis: Subject to Medical Necessity. There is no defined age limit for the use of reduced intensity conditioning for an allogeneic stem cell transplant.

Tandem transplants: Subject to medical necessity

Autologous tandem transplants for:

• Multiple myeloma (de novo and treated)
• Recurrent germ cell tumors (including testicular cancer) 

Transplants Under Clinical Trials 

Blood or Marrow Stem Cell Transplants

Allogeneic transplants for:

• Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
• Multiple myeloma
• Sickle Cell
• Beta Thalassemia Major

Non-myeloablative allogeneic transplants for:

• Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
• Hodgkin’s lymphoma
• Chronic lymphocytic leukemia 
• Chronic myelogenous leukemia 
• Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL) relapsed/refractory disease 
• Early stage (indolent or non-advanced) small cell lymphocytic lymphoma 
• Multiple Myeloma 
• Myeloproliferative Disorders MD Review
• Myelodysplasia/Myelodysplastic Syndromes 
• Sickle Cell disease 

Autologous transplants for: 

• Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL) 
• Early stage (indolent or non-advanced) small cell lymphocytic lymphoma 

Rare Organ/Tissue Transplant

Allogeneic transplants for:

• Advanced neuroblastoma
• 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 MD REVIEW
• Sickle cell anemia
• X-linked lymphoproliferative syndrome

Autologous transplants for:

• Ependymoblastoma
• Ewing’s sarcoma
• Medulloblastoma
• Pineoblastoma
• Waldenstrom’s macroglobulinemia MD REVIEW

No charge

20% coinsurance

Deductible applies

10% coinsurance

Deductible applies

All charges

All charges

Not covered:

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

All charges

Professional services provided in –

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

No charge

20% coinsurance 

Deductible applies

10% coinsurance

Deductible applies

Room and board, such as

• Semiprivate, or intensive care accommodations;
• General nursing care
• Meals and special diets

Note: If you want a private room when it is not medically necessary, you will be responsible for paying the additional charge above the semiprivate room rate.

No charge

20% coinsurance 

Deductible applies

10% coinsurance

Deductible applies

Other hospital services and supplies, such as:

• Operating, recovery, maternity delivery, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and x-rays
• Administration of blood and blood products
• Blood or blood plasma, if not donated or replaced
• Dressings, splints, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

No charge

10% Coinsurance for all inpatient and outpatient labs and x-rays. 

20% coinsurance 

Deductible applies

10% coinsurance

Deductible applies

Not covered:

• Custodial care
• Leave of absence or bed-hold charges incurred when you are on an overnight or weekend pass during an inpatient stay
• Personal comfort items, such as telephone, television, barber services, guest meals and beds
• Private duty nursing

All charges

All charges

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

Note: We cover hospital services and supplies related to dental procedures when necessitated by a non-dental physical impairment. We do not cover the dental procedures.

No charge for outpatient hospital visit or at an ambulatory surgery center

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

20% coinsurance 

Deductible applies

10% coinsurance

Deductible applies

Not covered:

• Certain outpatient medical supplies that are consumable or disposable supplies, including, among other things, gloves, diapers, adhesive bandages, elastic bandages, and gauze

• Personal comfort items, such as telephone, television, barber services, guest meals and beds

• Private nursing care

All charges

All charges

All charges

Care and treatment, including therapy, and room and board in semi-private accommodations are covered up to a combined benefit maximum of  45  days per year when provided in an of the following facilities:

• Skilled nursing 
• Subacute
• Inpatient rehabilitation 

No charge

20% coinsurance

Deductible applies

10% coinsurance

Deductible applies

• Admission to a skilled nursing, subacute or inpatient rehabilitation facility if the necessary care or therapies can be provided safely in a less intensive setting, including the home or a provider office
• Care provided in a facility required to protect you against self-injurious behavior 
• Custodial Care, even if you receive skilled nursing services or therapies along with custodial care
• Leave of Absence - Bed-hold charges incurred when you are on an overnight or weekend pass during an inpatient stay
• Non-skilled care received in a residential facility or assisted living facility on a temporary or permanent basis

All charges

The following hospice care services, provided as part of an established hospice program, are covered when your physician informs us that your condition is terminal and hospice care would be appropriate:

• Inpatient hospice care.  Short-term inpatient care in a licensed hospice facility is covered when skilled nursing services are required and cannot be provided in other settings.  Prior approval of inpatient hospice care is required.
• Outpatient hospice care.  Outpatient care is covered when intermittent skilled nursing services by a registered nurse or a licensed practical nurse are required or when medical social services under the direction of a physician are required.  Outpatient hospice care is any care provided in a setting other than a licensed hospice facility.  Hospice Care provided while you are in a hospital or skilled nursing facility is considered outpatient hospice care.
• Respite Care.  Respite care in a facility setting is covered as outlined in our medical policies.

No charge for care provided in the home

Any hospice services provided in a facility will be subject to the appropriate facility benefit 

No charge for care provided in the home

Any hospice services provided in a facility will be subject to the appropriate facility benefit 

No charge for care provided in the home

Any hospice services provided in a facility will be subject to the appropriate facility benefit  

• Custodial care
• Private duty nursing

All charges

Advance care planning activity is covered for all members

Palliative care for serious chronic illness or terminal illness is part of a member's medical  benefit

No charge

20% coinsurance

Deductible applies

10% coinsurance

Deductible applies

$150 copayment

$150 copayment

Deductible applies

$150 copayment

Deductible applies

Not covered:

• Non-emergency transportation unless you receive prior approval

All charges

Urgent care center services

$75 copayment

Deductible does not apply

$75 copayment

Deductible applies

Emergency room services

$200 copayment, waived if admitted

$200 copayment, waived if admitted

Deductible applies

$200 copayment, waived if admitted

Deductible applies

• Elective care 
• Non-emergency care
• Urgent care services provided by a non-network provider within our service area

All charges

All charges

All charges

Urgent care center services

$75 copayment

Deductible does not apply

$75 copayment

Deductible applies

Emergency room services

$200 copayment, waived if admitted

$200 copayment, waived if admitted

Deductible applies

$200 copayment, waived if admitted

Deductible applies

Not covered: 

• Elective care 
• Non-emergency care

All charges

All charges

All charges

$150 copayment

$150 copayment

Deductible applies

$150 copayment

Deductible applies

Not covered:

• Non-emergency transportation unless you receive prior approval 

All charges

All charges

All charges

This plan covers evaluation, consultation and treatment necessary to determine a diagnosis and treatment plan for both acute and chronic mental health conditions.  Both crisis intervention and medically/clinically necessary treatment of ongoing and/or chronic mental health conditions are covered.  Covered services must be:

1. Provided by licensed behavioral health professionals acting within the scope of their license, such as psychiatrists, psychologists, clinical social workers, licensed professional counselors, or  family therapists;
2. Provided in licensed behavioral health treatment facilities; and
3. Medically/clinically necessary and based on evidence-based standards for treatment of your condition.

Mental health services are available in a variety of settings.  You may be treated as an inpatient or as an outpatient depending on your particular condition.  Services will generally be provided in the least restrictive place that will allow for the best results for any particular condition.  If you don’t know where to go for treatment, call our Behavioral Health Department at 616 464-8500 or 800 673-8043 to speak with a trained clinician who can assist you.  Covered treatment settings include:

• Acute Inpatient Hospitalization
• Residential Treatment
• Partial Hospitalization
• Intensive Outpatient Treatment
• Outpatient Treatment 

Mental health inpatient care includes residential treatment facility and partial hospitalization care.  

Mental health outpatient care includes medication management visits.  

$10 copayment for outpatient service

$15 copayment for outpatient services

20% coinsurance for inpatient services

Deductible applies  

$10 copayment for outpatient services

10% coinsurance for inpatient services

Deductible applies  

Teletherapy Visits - Behavioral Health

Virtual (video) visits are available 24/7.  To schedule a teletherapy visit, please schedule your visit through your member center at www.priorityhealth.com.

No charge

No charge

No charge

Certain conditions have unique coverage limitations as stated below. Treatment for medical complications related to these conditions, including but not limited to neuropsychological testing, when appropriate, is covered.  

• Eating disorders, and feeding disorders of infancy or childhood, are covered at all levels of care described above based on our medical policies.   
• Personality disorders are covered only for specific psychological testing to clarify the diagnosis.   
• Organic brain disorders are covered for initial evaluation to clarify the diagnosis and for follow-up psychiatric medication management. Inpatient services for members with organic brain disorders, such as closed head Injuries, Alzheimer's and other forms of dementia, are covered based on our medical policies.    
• Autistic Disorder, including Asperger’s Disorder and Unspecified Pervasive Developmental Disorder not otherwise specified, are covered for evidence based treatment services.  (See the Autism Spectrum Disorder Treatment section for covered services and limitations.)
• Intellectual Disabilities are covered for initial evaluation and follow up psychiatric medication management. 

$10 copayment for outpatient services

$15 copayment for outpatient services

20% coinsurance inpatient services

Deductible applies

$10 copayment for outpatient services

10% coinsurance for inpatient services

Deductible applies  

When medically/clinically necessary, covered substance use services, include but are not limited to:

• counseling 
• medical testing
• diagnostic evaluation
• detoxification services 

Covered treatment includes:

• Inpatient Detoxification
• Medically Monitored Intensive Inpatient Treatment
• Residential Treatment
• Partial Hospitalization
• Intensive Outpatient Programs, no preauthorization required
• Outpatient Treatment
• Outpatient/Ambulatory Detoxification

$10 copayment for outpatient services

$15 copayment for outpatient services

20% coinsurance inpatient services

Deductible applies

$10 copayment for outpatient services

10% coinsurance inpatient services

Deductible applies

Mental health services that are not covered include: 

• Care provided in a non-licensed residential or institutional facility, such as the costs of living and being cared for in transitional living centers, foster care facilities, therapeutic boarding schools, wilderness therapy programs, custodial care or halfway houses
• Counseling and other services for antisocial personality, insomnia and other non-medical sleep disorders, marital and relationship enhancement, and religious oriented counseling provided by a religious counselor who is not a Plan provider
• Experimental/investigational or unproven treatments and services
  
• Scholastic/educational testing

Substance use services that are not covered include: 

• Non-skilled care received in a home or facility on a temporary or permanent basis 
• Experimental/investigational or unproven treatments and services

Note: OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.

All charges

Covered outpatient prescription drugs include some or all of the following:

• Federal legend drugs medicinal substances available only through prescription. 
• State-restricted drugs medicinal substances which, according to state law, may only be dispensed by prescription.
• Compounded medications medicinal substances compounded by the pharmacist which have at least one ingredient that is federal legend or state-restricted in a therapeutic amount.
• Injectable insulin and disposable syringes and needles for administration of injectable insulin; nonexperimental medication for controlling blood sugar and medication used in the treatment of ailments, infections or medical conditions of the foot, ankle or nails associated with diabetes. (Note: Diabetic supplies such as blood glucose monitors, syringes, lancets, blood glucose test strips, insulin pumps, shoe inserts for members with diabetic neuropathy, and special shoes prescribed for a person with diabetes when medically/clinically necessary can be purchased at a Plan pharmacy and your applicable prescription drug copayment will apply. These supplies are covered in full if obtained from a participating Durable Medical Equipment (DME) provider.  
• Drugs used for the treatment of gender dysphoria or gender transformation, such as FDA-approved medications for hormone therapy according to standard requirements for the particular drug (prior approval or step therapy may apply). Hormone therapy for the treatment of gender dysphoria or gender transformation is covered as prescribed by your provider, regardless of gender.
• Naloxone 2mg and 2ml strength is covered at no charge.
• Growth Hormone Treatment - requires prior approval;

If there is no generic equivalent available, you will still have to pay the applicable brand name copayment. 

Retail Prescriptions: 

$15 copayment per Generic prescription

$50 copayment for Preferred-brand prescription

$80 copayment for Non-preferred Brand prescription

20% coinsurance for Preferred Specialty drugs - The maximum copayment for Preferred Specialty drugs is $150 per fill.  Prior approval required

20% coinsurance for Non-preferred Specialty drugs - The maximum copayment for Non-preferred Specialty drugs is $300 per fill. Prior approval required

There is no deductible on this plan.  You just pay the copayments listed.

Mail Order: Two applicable copayments  for a 90-day supply of Generic, Preferred-brand or Non-preferred brand prescription drugs

Retail Prescriptions: 

$20 copayment per Generic prescription

$60 copayment for Preferred-brand prescription

$90 copayment for Non-preferred brand prescription

20% coinsurance for Preferred Specialty drugs - The maximum copayment for Preferred Specialty drugs is $200 per fill. Prior approval required

20% coinsurance for Non-preferred Specialty drugs - The maximum copayment for Non-preferred Specialty drugs is $400 per fill. Prior approval required

Deductible does not apply to outpatient prescription drugs 

Mail Order: Two applicable copayments  for a 90-day supply of Generic, Preferred-brand or Non-preferred brand prescription drugs

Retail Prescriptions: 

$20 copayment per Generic prescription

$60 copayment for Preferred-brand prescription

$90 copayment for Non-preferred brand prescription

20% coinsurance for Preferred Specialty drugs - The maximum copayment for Preferred Specialty drugs is $200 per fill. Prior approval required

20% coinsurance for Non-preferred Specialty drugs - The maximum copayment for Non-preferred Specialty drugs is $400 per fill. Prior approval required

Deductible does not apply to outpatient prescription drugs 

Mail Order: Two applicable copayments  for a 90-day supply of Generic, Preferred-brand or Non-preferred brand prescription drugs

Contraceptive drugs and devices as listed in the ACA/HRSA site.  Contraceptive coverage is available at no cost to FEHB members. The contraceptive benefit includes at least one option in all methods of contraception (as well as the screening, education, counseling, and follow-up care). Any contraceptive that is not already available without cost sharing on the formulary can be accessed through the contraceptive exceptions process described below. 

Generic contraceptives (including generic emergency contraceptives) are Covered under preventive health care services at no cost share to you as outlined in Priority Health's Preventive Health Care Guidelines. A brand name contraceptive may be Covered under preventive health care services at no cost share to you when there is no generic equivalent for the same contraceptive method, or if approved by Priority Health as medically/clinically Necessary. All other brand name contraceptive drugs are subject to the applicable Brand Name Drugs copayment described below. Restrictions may apply to Members of (a) religious employer plans certified as exempt under the Patient Protection and Affordable Care Act; and (b) plans certifying Eligible Organization Accommodations under provisions of the Patient Protection and Affordable Care Act.

No charge

Preventive care medications

Medications to promote better health as recommended by ACA.

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.

• 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
• Liquid iron supplements for children age 6 months -1 year
• Vitamin D supplements (prescription strength) (400 & 1000 units) for members 65 or older
• Prenatal vitamins for pregnant women
• Fluoride tablets, solution (not toothpaste, rinses) for children age 0 - 6 months
• Oral chemotherapy 
• FDA approved tobacco-cessation products are covered for up to 3 months.  Coverage is continued for an additional 3 months if you have successfully quit smoking (a maximum of 6 months per calendar year)

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

No charge

No charge

No charge

Covered medical pharmacy services drugs include those administered in an inpatient or emergency setting or those requiring an injection or infusion by a health professional in a medical office, home or outpatient facility.

Note: Coverage for selected injectable drugs in certain categories is covered under the outpatient prescription drug benefit above.

20% coinsurance for a Preferred Specialty Drug. The maximum copayment for a Preferred Specialty Drug is $150

20% coinsurance for a Non-preferred Specialty Drug. The maximum copayment for a Non-preferred Specialty Drug is $300

Prior approval required

20% Coverage for a Preferred Specialty Drug. The maximum copayment for a Preferred Specialty Drug is $200

20% Coverage for a Non-preferred Specialty Drug. The maximum copayment for a Non-preferred Specialty Drug is $400

Prior approval required

Deductible will apply to covered inpatient medical plan pharmacy services.

20% Coverage for a Preferred Specialty Drug. The maximum copayment for a Preferred Specialty Drug is $200

20% Coverage for a Non-preferred Specialty Drug. The maximum copayment for a Non-preferred Specialty Drug is $400

Prior approval required

Deductible will apply to covered inpatient medical plan pharmacy services.

50% coinsurance for up to 6 pills per 30 days (oral and non-oral)

50% coinsurance for up to 6 pills per 30 days (oral and non-oral)

50% coinsurance for up to 6 pills per 30 days (oral and non-oral)

50% coinsurance

Naloxone therapy (2mg and 2ml strength)

No charge

No charge

No charge

Anti-Obesity Medications (specific oral and GLP-1s)

Note: GLP-1s require prior authorization

Applicable cost share depending on tier structure of drug

Applicable cost share depending on tier structure of drug

Applicable cost share depending on tier structure of drug

Gene Therapy (Prescription Drugs)

All Priority Health plans include coverage of services, drugs and supplies related to the treatment of gender dysphoria.

Covered services, when medically necessary, are available for all members subject to medical policy. 

Preventive services are covered subject to the plan benefits, including Affordable Care Act requirements, as recommended by a member’s physician regardless of the member’s gender assigned at birth. Gender edits are not in place on our prescription drug formulary to ensure members are able to access covered drugs when prescribed by an authorized provider.

No charge.  If an office visit is billed, the office visit copayment will be $10 for a PCP and $35 for a Specialist. There is no member cost share for an outpatient or inpatient facility.

No charge.  If an office visit is billed, the office visit copayment will be $15 for a PCP and $45 for a Specialist. The member cost share for an outpatient or inpatient facility will be 20%, subject to the deductible.

No charge.  If an office visit is billed, the office visit copayment will be $10 for a PCP and $35 for a Specialist. The member cost share for an outpatient or inpatient facility will be 10%, subject to the deductible.

Not covered:

• Drugs which do not, by federal or state law, require a prescription order (over-the-counter (OTC) drugs) or prescribed drugs for which there is an OTC equivalent available without a prescription order (such as Lotrimin).  We may elect to include certain OTC drugs on the Approved Drug List, based on recommendations made by our Pharmacy and Therapeutics Committee.  OTC drugs listed in Preventive Health Care Guidelines are Covered.
• Schedule V controlled substances available without a prescription order.
• Cosmetics or any drugs used for cosmetic purposes (such as, for example, drugs for the treatment of wrinkles, hair loss, and health or beauty aids).
• Men’s contraceptives.
• Multivitamins (except prenatal vitamins); nutritional supplements (except when these are the only means of nutrition); and drugs used for the purpose of weight reduction, such as appetite suppressants.
• Any medication prescribed in a manner other than in accordance with our procedures.
• Replacement of lost or damaged prescriptions.
• Drugs not approved by the Food and Drug Administration (FDA) under the Federal Food, Drug and Cosmetic Law and regulations.
• Refills in excess of the amount specified by the prescriber, and any refill dispensed after one year from the order of the prescriber.  Specialty drugs in excess of a 31-day supply are not covered even if specified by the prescriber.

All charges

All charges

All charges

$35 copayment in a Specialist office

$45 copayment in a Specialist office

Deductible does not apply

$35 copayment in a Specialist office

Deductible applies

We have no other dental benefits

All Charges

All Charges

All Charges

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

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

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 Provider 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: www.assistamerica.com

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.

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.

The Active&Fit Direct program allows you to choose from 9,000+ participating fitness centers nationwide for $28 a month (plus a $28 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

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.

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 by doing the following:

• 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.

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.

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

If you live in a county where at least 10 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 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: 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.

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 healthcare professional with knowledge of your medical condition may act as your authorized representative without your express consent.

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

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

If you do not agree with OPM’s decision, your only recourse is to 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 family member 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 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, contact Priority Health Customer Service at 800-446-5674.

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 processes the benefit, we will pay what is left of our allowance, up to our regular benefit.  We will not pay more than our allowance.

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

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

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

We do not cover services that:

• You (or a covered family member) need because of a workplace-related illness or injury that the Office of Workers’ Compensation Programs (OWCP) or a similar federal or state agency determines they must provide; or
• OWCP or a similar 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.

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.

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.

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 www.BENEFEDS.com or by phone at 1-877-888-3337, (TTY 1-877-889-5680), you will be asked to provide information on your FEHB plan so that your plans can coordinate benefits. Providing your FEHB information may reduce your out-of-pocket cost.

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

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

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

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

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

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

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

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

When we are the primary 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 www.priorityhealth.com.

We waive some costs if you have Medicare Part A and B and your Original Medicare Plan is your primary payor.  

• Medical services and supplies provided by physicians and other healthcare professionals

Please review the following examples which illustrates your cost share if you are enrolled  Medicare Part A and 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 - you pay $0 with Medicare Part B for all plans (high, standard, value)
High Option You pay without Medicare Part A and B: $0.00
Standard Option You pay without Medicare Part A and B:$350 Self Only $700 Self Plus One and Self and Family
Value Option you pay without Medicare Part A and B: $1,500 Self Only $3,000 Self Plus One and Self and Family

Benefit Description: Primary Care Provider - you pay $0 with Medicare Part B for all plans (high, standard, value)
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

Benefit Description: Specialist - you pay $0 with Medicare Part B for all plans (high, standard, value)
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

Benefit Description: Inpatient Hospital - you pay $0 with Medicare Part B for all plans (high, standard, value)
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%


Benefit Description: Outpatient Hospital - you pay $0 with Medicare Part B for all plans (high, standard, value)
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%

Benefit Description: Emergency Care - you pay $0 with Medicare Part B for all plans (high, standard, value)
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


Benefit Description: Ambulance Services - you pay $0 with Medicare Part B for all plans (high, standard, value)
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

Benefit Description: Urgent Care - you pay $0 with Medicare Part B for all plans (high, standard, value)
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

Benefit Description: Durable Medical Equipment / Prosthetics & Orthotic - you pay $0 with Medicare Part B for all plans (high, standard, value)
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 can find more information about how our plan coordinates benefits with Medicare at www.priorityhealth.com.

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 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: Priority Health does not offer a Medicare Advantage Plan through the FEHB plan.  You may enroll in one of the Individual Medicare Advantage plans offered by Priority Health (non-FEHB) 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 an Individual Medicare Advantage plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare Advantage plan premium.) For information on suspending your FEHB enrollment, contact your retirement or employing office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage or move out of the Medicare Advantage plan’s service area.

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

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

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

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

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

• Medicare was the primary payor before eligibility due to ESRD

• Medicare based on age and disability

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

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

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

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

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

• 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.

See Section 4, page 25.

See Section 4, page 25.

See Section 4, page 25.

See Section 4, page 26.

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

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.

The inability to conceive a successful pregnancy after 12 months of egg-sperm contact if the individual is under the age of 35 or after 6 months if the individual is age 35 and older. Infertility may also be justified based on the individual having a medical or other recognized condition as a cause of infertility.

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.  

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

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.

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.  

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.

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.

An FEHB Employee or FEHB Annuitant.

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.

Surprise bill

An unexpected bill you receive for

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

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.

$10 copayment Primary Care Provider; $35 copayment Specialist

33-47

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

61-64

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

61-64

$75 copayment

65-66

$75 copayment

65-66

$200 copayment per visit, waived if admitted

65-66

$200 copayment per visit, waived if admitted

65-66

Regular cost-sharing

67-70

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

71-77

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

78

No coverage for routine eye exam

42

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

14

$15 copayment Primary Care Provider; $45 copayment Specialist 

33-47

20% coinsurance

61-64

20% coinsurance

61-64

$75 copayment

65-66

$75 copayment

65-66

$200 per visit, waived if admitted

65-66

$200 per visit, waived if admitted

65-66

Regular cost-sharing

67-70

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 

71-77

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

78

No coverage for routine eye exam

42

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

14

Office visit copayment: $10 copayment Primary Care Provider; $35 copayment Specialist*

33-47

10% coinsurance

61-64

10% coinsurance

61-64

$75 copayment

65-66

$75 copayment

65-66

$200 copayment per visit, waived if admitted

65-66

$200 copayment per visit, waived if admitted

65-66

Regular cost-sharing

67-70

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 

71-77

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

78

No coverage for routine eye exam

42

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

14