Coverage under this plan qualifies as minimum essential coverage.  Please visit the Internal Revenue Service (IRS) website at www.irs.gov/affordable-care-act/individuals-and-families/questions-and-answers-on-the-individual-shared-responsibility-provision for more information on the individual requirement for MEC.

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

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

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

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

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

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

Self Only coverage is only for the enrollee. Self Plus One coverage is for the enrollee and one eligible family member.  Self and Family coverage is for the enrollee and one or more eligible family 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 and  Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment form.  Benefits will not be available to your spouse until you are married.  A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

Contact your 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 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 other eligible family member as described below.

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

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

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

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

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

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

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

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

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

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

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

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

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2025 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 2024 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 all services received directly from your provider.  You may be prosecuted for fraud for knowingly using health insurance benefits for which you have not paid premiums.  It is your responsibility to know when you or a family member are no longer eligible to use your health insurance coverage.

When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your Federal service. If you do not meet this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of Coverage (TCC).

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.

You may be eligible for spouse equity coverage or assistance with enrolling in a conversion policy (non-FEHB individual policy).

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, 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 FEHB Program coverage.

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

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

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

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed, and your coverage will not be limited  due to pre-existing conditions. When you contact us, we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act’s Health Insurance Marketplace in your state. For assistance in finding coverage, please contact us at 800-522-0088 or visit our website at www.healthnet.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 Plan provider or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 800-522-0088 or write to us at Health Net of California, PO Box 9103, Van Nuys, CA 91409-9103. You may also request replacement cards through our Website www.healthnet.com/fehb.

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

Plan providers are participating physician groups, physicians and other healthcare professionals in our service area that we 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 maintain stringent credentialing and recredentialing criteria for our Plan Providers.

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.

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

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

This plan provides Care Coordinators for complex conditions and can be reached at 800-522-0088 for assistance.

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

You must select a Participating Physicians Group (PPG) within a 30 mile radius of your home or work-site. Each family member may choose their own PPG and primary care provider.

You may transfer to another PPG by calling us at 800-522-0088. You may change PPG’s once a month or upon our approval.  The request will be denied if you are more than three months pregnant, confined to a hospital, in a surgery follow-up period (not yet released by the surgeon) or receiving treatment for an illness that is not yet complete.

Your primary care provider can be a family practitioner, internist or pediatrician. Your primary care provider will provide most of your healthcare, or give you a referral to see a specialist.  If you want to change primary care provider or if your primary care provider leaves the Plan, call us. We will help you select a new one.

Your primary care provider will refer you to a specialist for needed care. When you receive a referral from your primary care provider, you must return to the primary care provider after the consultation, unless your primary care provider authorized a certain number of visits without additional referrals. The primary care provider must provide or authorize all follow-up care. Do not go to the specialist for return visits unless your primary care provider gives you a referral. However, you may see a participating chiropractor (as described on page 41) and a woman may see her participating gynecologist at anytime without a referral.

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

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

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

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

• If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.
• If you are a new Health Net of California member and are currently receiving treatment for a qualifying medical condition from a provider who is not in our network, you may be eligible to complete treatment of your condition with the provider. Or, if you are an existing member and are currently receiving treatment for a qualifying medical condition from a provider who is leaving our network, you may be eligible to complete treatment of your condition with the provider. In order to receive more information about continuity of care and qualifying medical conditions and situations, please contact us at 800-522-0088 and we will assist you.

You also have the right to a second opinion when:

• your primary care provider or a referral physician gives a diagnosis or recommends a treatment plan that you are not satisfied with;
• you are not satisfied with the result of treatment you have received; 
• you are diagnosed with, or a treatment plan is recommended for a condition that threatens loss of life, limb or bodily function, or a substantial impairment, including but not limited to a serious chronic condition; or
• your primary care provider or a referral physician is unable to diagnose your condition, or test results are conflicting.

To request an authorization for a second opinion, contact your Primary Care Provider or Health Net of California Member Services at 800-522-0088. Physicians at your Physician Group or Health Net of California will review your request in accordance with Health Net of California’s second opinion policy. You may obtain a copy of this policy from Health Net of California’s Member Service Department. All second opinions must be provided by a participating network physician who specializes in the illness, disease or condition associated with the request. If there is no appropriately qualified physician in the network, your primary care provider will arrange for an out-of-network second opinion.

Your Plan 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 800-522-0088. If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

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

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

These provisions apply only to the benefits of the hospitalized person. If your plan terminates participation in the FEHB Program in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such cases, 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, the pre-service claim approval process only applies to care shown under Other services.  You must get prior approval for those services listed.  Failure to do so will result in denied claims and member will be responsible for the full cost.

Precertification is the process by which - prior to your inpatient hospital admission - we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition.

Your primary care provider has authority to refer you for most services.  For certain services, however, your physician must obtain prior approval from us.  Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice.  You must obtain prior authorization for some services such as but not limited to:

• Acute rehabilitation and behavioral health facility admissions
• Air ambulance and non-emergent ambulance transportation
• All bariatric-related consultations, services and surgical services
• Clinical trials
• Durable medical equipment
• Home health services, including but not limited to IV infusion, hospice
• Outpatient diagnostic procedures, including but not limited to CT, MRA, MRI, PET and SPECT
• Transplants
• Growth Hormone Treatment (GHT)
• Certain formulary and non-formulary prescription drugs

Services that are not authorized by your primary care provider or Health Net of California will not be covered.

First, your physician, your hospital, you, or your representative, must call us at 800-977-7282 before admission or services requiring prior authorization are rendered.

Next, provide the following information:

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

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

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

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

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

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

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM.  Please let us know that you would like 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 800-522-0088.  You may also call OPM's FEHB 3 at 202-606-0737 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review.  We will cooperate with OPM so they can quickly review your claim on appeal.  In addition, if you did not indicate that your claim was a claim for urgent care, call us at 800-522-0088.  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 phone us within two business days 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 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.

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.

Prior authorization may be obtained by you or your Provider.  Coverage for those services will be provided only if Prior Authorization has been obtained from us.  If a Member receives care from a nonparticipating Physician or other healthcare Provider without a required Prior Authorization, the Member shall be responsible for the cost of these services.  Failure of the nonparticipating Provider to obtain the Prior Authorization shall in no way relieve the Member of the financial responsibility for services received from that Provider.

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

If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below.  If your claim is in reference to a contraceptive, call Member Services at 800-522-0088.

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

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

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

1. Pre-certify 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 of 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.

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

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

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

Example: When you see your primary care provider, you pay a copayment of $20 per office visit.  When you go in the hospital you pay $150 per day (5 day max copay) per admission.

Example: In our Plan, you pay 50% of our allowance for infertility services and 20% to a maximum of $200 per day for injectable medications.

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

After your copayments and/or coinsurance for the High Option plan total $1,500 for Self Only, $3,000 for Self Plus One or $4,500 for Self and Family enrollment in any calendar year, you do not have to pay any more for covered services. However, your prescription drug benefit on the High plan has a separate out-of-pocket maximum of $2,900 for Self Only, $5,800 for Self Plus One and $8,700 for Self and Family that must be met before prescription copayments or coinsurance are waived.  

The maximum annual limitation on cost sharing listed under Self Only of $1,500 for the High Option applies to each individual, regardless of whether the individual is enrolled in Self Only, Self Plus One, or Self and Family.

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

• Eyeglasses or contact lenses
• Copayments or coinsurance for infertility treatment
• Expenses for services and supplies that exceed the stated maximum dollar or day limit
• Expenses from utilizing out-of-network providers

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.

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. 

In addition, your health plan adopts and complies with the surprise billing laws of California. For specific information on surprise billing, the rights, and protections you have, and your responsibilities go to https://www.healthnet.com/content/healthnet/en_us/members.html or contact the plan at 800-522-0088.

Per section 2799A-5(c) of the PHS Act, section 9820(c) of the Internal Revenue Code, section 720(c) of the Employee Retirement Income Security Act -

For more information, please visit our website at www.healthnet.com on:

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 an FSA participant for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, over-the-counter drugs and medications, vision and dental expenses, and much more) for their tax dependents, and their 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 or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.  

Professional services of physicians

• In physician’s office

Professional services of healthcare professionals at CVS MinuteClinics

$20 per visit

Preventive Care Services at CVS MinuteClinics

Nothing

Professional services of physicians

• In an urgent care center
• Office medical consultations
• Second surgical opinion
• At home

$20 per visit

Professional services of physicians

• During a hospital stay
• In a skilled nursing facility

Immunizations for occupational and foreign travel

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. 

20% of charges

Not covered:

• Treatment that is not authorized by a plan physician
• Treatment that is not medically necessary

All charges

Telehealth consultations (virtual visit) provided by Health Net's preferred vendor board-certified doctors and pediatricians by secure video, mobile app or phone.  Available 24 hours, 7 days a week for non-emergency conditions such as:

• Allergies
• Cold/flu
• Ear problems
• Respiratory problems
• Sore throats
• Urinary problems/UTI

Note: 

Telehealth services (virtual visit) also include access to behavioral therapy services including mental health and substance use disorder treatment.

For more information, please visit www.healthnet.com/fehb.

Telehealth consultations (virtual visit) provided by the physicians in your medical group.

$20 per PCP office visit, $30 per specialist visit

Tests, such as:

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

Routine physical every year

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

• U.S. Preventive Services Task Force (USPSTF) A and B recommended screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer.  For a complete list of screenings go to the 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 care benefits  for women please visit the Health and Human Services (HHS) website at
  www.hrsa.gov/womens-guidelines
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder

Nothing

• Routine mammogram 

• Adult immunizations endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule. For a complete list of endorsed immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/

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.

Obesity counseling, screening and referral for those persons at or above the USPSTF obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:

• Intensive nutrition and behavioral weight-loss counseling therapy,

• Family centered programs when medically identified to support obesity prevention and management by an in-network provider.

Nothing

• When anti-obesity medication is prescribed as indicated by the FDA obesity medication treatment guidelines. See Section 5(f) for cost share requirements for anti-obesity medications.

See Section 5(f) for cost share requirements for anti-obesity medications.

• When Bariatric or Metabolic surgical treatment or intervention is indicated for severe obesity. See Section 5(b) for surgery requirements and cost share.

See Section 5(b) for surgery requirements and cost share.

Not covered

• Physical exams and immunizations required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or travel.

• Well-child visits, examinations, and other immunizations 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.

• Children's immunizations endorsed by the Centers for Disease Control (CDC) including DTaP/Tdap, Polio, Measles, Mumps, and Rubella (MMR),and Varicella. For a complete list of immunizations go to the website at https://www.cdc.gov/vaccines/schedules/index.html

• You can also find a complete list of 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.

Obesity counseling, screening and referral for those persons at or above the USPSTF obesity prevention risk factor level, to intensive nutrition and behavioral weight-loss therapy, counseling, or family centered programs under the USPSTF A and B recommendations are covered as part of prevention and treatment of obesity as follows:

• Intensive nutrition and behavioral weight-loss counseling therapy,
• Family centered programs when medically identified to support obesity prevention and management by an in-network provider.
  
  

Nothing

• When anti-obesity medication is prescribed as indicated by the FDA obesity medication treatment guidelines. See Section 5(f) for cost share requirements for anti-obesity medications.

See Section 5(f) for cost share requirements for anti-obesity medications.

• When Bariatric or Metabolic surgical treatment or intervention is indicated for severe obesity. See Section 5(b) for surgery requirements and cost share.

See Section 5(b) for surgery requirements and cost share.

Not covered: Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, athletic exams, or for travel.

Complete maternity (obstetrical) care, such as:

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

$20 per visit PCP office visit, $30 per specialist visit

Breastfeeding and lactation support, supplies and counseling for each birth    

Delivery

Note: Here are some things to keep in mind:

You do not need to precertify your vaginal delivery; see page 19 for other circumstances, such as extended stays for you or your baby.

• You do not need to pre-certify your vaginal delivery;
• As part of your coverage, you have access to in-network certified nurse midwives, home nurse visits and board-certified lactation specialists during the prenatal and post-partum period. This plan also includes a doula program, please see Section 5(a) under Educational Classes and Program, and Section 5(h) under Wellness and Other Special Features.
• You may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a cesarean delivery. We will extend your inpatient stay if medically necessary.
• We cover routine nursery care of the newborn child during the covered portion of the mother’s maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. 
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).

Note: When a newborn requires definitive treatment during or after the mother’s 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.  In addition, circumcision is covered at the same rate as for regular medical or surgical benefits.

A range of voluntary family planning services, without cost sharing, that includes at least one form of contraception in each of the categories on the HRSA list. This list includes:

• Voluntary female sterilization
• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo Provera)
• Intrauterine devices (IUDs)
• Diaphragms

Note: See additional Family Planning and Prescription drug coverage Section 5(f)

Note: Your plan offers some type of voluntary female sterilization surgery coverage at no cost to members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories of contraception (as well as the screening, education, counseling, and follow-up care). Any type of voluntary female sterilization surgery that is not already available without cost sharing can be accessed through the contraceptive exceptions process described below.

• Use the contraception exception process if the contraception recommended by your provider is not covered or has an out-of-pocket cost. You or your provider may submit an exception request.
• Members can call the Customer Contact Center at 1-800-522-0088 to submit an exception request.

If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.

• Voluntary male sterilization

Nothing

Genetic testing for mother/child is subject to medical necessity and experimental/investigational review by the Plan. 

Cell-free fetal DNA testing is a screening test of the woman’s blood taken after 10 weeks of pregnancy. It measures the relative amount of free fetal DNA and indicates if the fetus is at increased risk of having Down syndrome (trisomy 21), Edwards syndrome (trisomy 18) and Patau syndrome (trisomy 13).

One cell-free fetal DNA test per pregnancy is
medically necessary for members meeting all
of the following criteria:

• Underwent pretest counseling, and
• Current pregnancy not a multiple gestation, and
• Current pregnancy between 10 and 22 weeks gestation at the time the blood was drawn, and
• High risk for fetal aneuploidy as evidenced by one of the following:
  • Maternal age >35 years at delivery, or
  • Maternal history of a child affected with trisomy, or
  • Abnormal ultrasound findings, or
  • Positive test result for aneuploidy, including first trimester, sequential, or integrated screen, or quadruple screen, or
  • A parent carrying a balanced Robertsonian translocation with increased risk of trisomy 13 or trisomy 21.

Cell-free fetal DNA testing for any indication not listed above is considered not medically necessary.

Cell-free fetal DNA testing for additional chromosomal abnormalities other than trisomy 21, 18 or 13 are considered not medically necessary, including, but not limited to, other trisomies, aneuploidies, or microdeletions.

Nothing

Cystic fibrosis and spinal muscular atrophy carrier testings are subject to medical
necessity and experimental/investigational review by the Plan.

Cystic fibrosis and spinal muscular atrophy carrier screenings medically necessary for women who are pregnant and meet the following criteria:

• No prior CF or SMA screening results are
  available, and
• Pregnancy 22 weeks gestation, and
• Underwent pretest counseling.

Cystic fibrosis and spinal muscular atrophy carrier screenings anytime other than during pregnancy are subject to medically necessary review by the Plan when meeting the most current version of the relevant nationally recognized decision support tools.

Nothing

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic counseling and testing not listed above

All charges

Infertility exists when any of the following apply to a Member: 

• The Member is a female (or individual with female reproductive organs) that has been unable to conceive pregnancy after 1 year of regular unprotected sex when under 35 years of age, or 6 months when age 35 and older, or when a pregnancy did occur, a live birth was not achieved; OR
• The Member has been unable to conceive pregnancy through attempted egg-sperm contact via artificial insemination; OR
• A licensed physician’s determination of infertility, based on the Member's medical, sexual, and reproductive history, age, physical findings, diagnostic testing, or any combination of those factors.

Diagnosis and treatment of infertility specific to:

• Artificial insemination (AI): Covered for six cycles only
  • Intravaginal insemination (IVI)
  • Intracervical insemination (ICI)
  • Intrauterine insemination (IUI)
  • Fertility drugs

• Embryo transfer and gamete intra-fallopian transfer (GIFT)
• Cryopreservation for embryos, oocytes and sperm which is limited to Iatrogenic and Gender Dysphoria
• Pre-implantation genetic testing (CPT code 81479 not covered)
• Donor oocytes (except for services that fall under IVF which is not a covered benefit)

Note: We cover injectable fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit. For further information, please view our clinical policy at https://www.healthnet.com/content/healthnet/en_us/providers/working-with-hn/medical_policies.html#clinical_practice_guidelines

In Vitro Fertilization (IVF)

Medications (oral and injectables) for up to 3 three cycles of IVF are covered 

50% of charges

Not covered:

• Assisted reproductive technology (ART) procedures, such as:
• In vitro fertilization (IVF) medical benefits
• Embryo transfer and zygote intra-fallopian transfer (ZIFT)
• Services and supplies related to ART procedures
• Cost of donor sperm, ova or their collection or storage
• Injectable medications for infertility treatments not covered by the plan

All charges

• Testing and treatment
• Allergy injections
• Allergy serum 

Not covered:

• Provocative food testing
• Sublingual allergy desensitization

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 48.

• Respiratory and inhalation therapy
• Dialysis – hemodialysis and peritoneal dialysis
• Applied Behavior Analysis (ABA) Therapy for Autism Spectrum Disorder

Nothing

• Intravenous (IV)/Infusion Therapy – Home IV or antibiotic therapy administered at home by home health nurse

$20 copay

• Cardiac rehabilitation following qualifying event/condition is provided in accordance with the treatment plan
• Growth hormone therapy (GHT)

Note: – 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 on page 18.

Nothing

20% to a maximum of $200 per day

Special food products and formulas

Coverage for testing and treatment of phenylketonuria (PKU) or other inborn errors of metabolism includes formulas and special food products that are part of a diet prescribed by a Physician and managed by a licensed health care professional in consultation with a Physician who specializes in the treatment of metabolic disease. The diet must be deemed Medically Necessary to prevent the development of serious physical or mental disabilities or to promote normal development or function. Coverage is provided only for those costs which exceed the cost of a normal diet.

Not Covered:
Other specialized formulas and nutritional supplements are not covered

Nothing

Services of each of the following:

• Qualified physical therapists
• Occupational therapists

Note:  We only cover therapy when a provider:

• 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.

Not covered:

• Long-term rehabilitative therapy
• Exercise programs
• When medical documentation does not support the medical necessity because of the member’s inability to progress toward the treatment plan goals or when the member has already met the treatment plan goals.

All charges

• Office Based - Therapeutic Injections
• Self Administered - acquired through specialty pharmacy with prescription
• Growth Hormone Therapy (GHT)

Note: Does not apply to: Allergy serum injections (see page 36); Injectable fertility drugs (see page 38); Routine immunizations (see page 29) and Immunizations for occupational and foreign travel (see page 27).

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

Note:  For routine hearing screening performed during a child's preventive care visit, see Section 5(a) Preventive care, children. 

$20 per PCP office visit, $30 per specialist visit 

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

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

$20 per PCP office visit, $30 per specialist visit 

Not covered:

• Hearing services that are not shown as covered

All charges

• One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts)
• Eye exam to determine the need for vision correction (see preventive care). Annual eye refractions

$20 per PCP office visit, $30 per specialist visit

Not covered:

• Eyeglasses or contact lenses
• Eye exercises and orthoptics
• Radial keratotomy and other refractive surgery
• Eyeglasses or contact lenses after Interocular lens implant

All charges

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

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

•  Artificial limbs and eyes
• Prosthetic sleeve or sock
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
• Corrective orthopedic appliances for 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. 

• External hearing aids for children  (under 18 years of age) with hearing loss - $1,500 maximum benefit every 36 months
• External hearing aids for adults - 2 hearing aids every 36 months with a maximum benefit of $1,500 every 36 months
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants 

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.

Not covered:

• Orthopedic and corrective shoes, arch supports, foot orthotics, except when they have been incorporated into a cast, splint, brace or strapping of the foot, or except to treat diabetes-related complications when prescribed by your Plan physician, heel pads and heel cups
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Prosthetic replacements provided less than 3 years after the last one we covered

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

• Oxygen
• Dialysis equipment
• Hospital beds
• Standard wheelchairs, electric wheelchairs if medically necessary
• Crutches
• Walkers
• Speech generating devices
• Blood glucose monitors
• Insulin pumps

Note: Call us at 800-522-0088 as soon your Plan physician prescribes this equipment.  We will arrange with a healthcare provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.  

Not covered:

• Exercise equipment
• Hygienic equipment and supplies (to achieve cleanliness even when related to other covered medical services)
• Stockings
• Surgical dressings, except primary dressings that are applied by a Plan physician or a Hospital to lesions of the skin or surgical incisions
• Jacuzzis and whirlpools
• Orthotics which are not custom made to fit your body (Orthotics are supports or braces for weak or ineffective joints or muscles)
• Foot orthotic, except when they have been incorporated into a cast, splint, brace or strapping of the foot
• Laptop computers, desktop computers or PDA's that are not dedicated speech generating devices are not covered

All charges

• Home healthcare ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide.
• Services include oxygen therapy, intravenous therapy and medications.

Note: Your Plan physician will review the home health service program for continuing appropriateness.

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

• Chiropractic and Acupuncture services – by the chiropractors/acupuncturists that participate in the American Specialty Health Plan (ASHP) network.

20 visits per calendar year are covered for these services without a referral from the Plan physician 

$10 per office visit

Acupuncture - by a doctor of medicine or osteopathy, or licensed or certified acupuncture practitioner.

Dry Needling - by a licensed or certified practitioner

Not covered:

• Naturopathic services
• Hypnotherapy
• Biofeedback
• Massage therapy

All charges

Coverage is provided for:

• Tobacco Cessation programs, including individual, group, telephonic counseling, over-the-counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence.
• The following Smoking/Tobacco Cessation prescribed medications:  Zyban, Chantix, Nicotrol Inhaler, and Nicotrol NS, dosage limits and prior authorization requirements apply
• FDA approved over-the-counter Nicotine replacement therapy medications.  Written prescription required and dosage limits apply
• Diabetes self management

Nothing

Nothing for drugs filled at a Plan pharmacy

Nothing for drugs filled through mail order program

Health Net's Wellness Programs
• Weight management

• Diabetes self-management

• Emotional health

• Exercise

• Nutrition

• Stress management

• Prenatal education

• Treatment support videos

• Diabetic Prevention Program

• Health Net Doula Program

A comprehensive range of services, such as:

• 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)
• Surgical treatment of severe obesity (bariatric surgery)

Health Net considers the following bariatric surgical procedures medically appropriate when all of the general criteria and all of the criteria specific to the procedures are met. Here is a list of the general criteria:

• Patient is an adult greater than 18 and less than 65 years of age unless the patient is greater than 65 and is considered a low-risk candidate;
• Morbid obesity has persisted for at least 5 years, especially in the year prior to the scheduled surgery;
• The patient has clinically severe obesity defined by either Body mass index greater than or equal to 40 kg/m2 or a weight of at least two times the ideal weight for frame, age, height, and gender, as specified in the 1983 Metropolitan Life Insurance tables; or BMI of between 35 kg/m2 and 40 kg/m2 with one or more of life-threatening, obesity-related co-morbidities which have not responded to optimal medical management.
• In the two years prior to the planned date of surgery, the patient has failed to lose weight or has regained weight despite participation in a six-month dietary program supervised by either a physician or professional.
• All patients must undergo a psychological evaluation by a psychiatrist/psychologist familiar with the implications of weight reduction surgery to rule out the presence of major psychological pathology (active substance abuse, schizophrenia, borderline personality disorder, uncontrolled depression) and to determine whether the patient will comply with the strict postoperative diet and lifelong follow-up.
• Treatable metabolic causes for obesity, especially hypothyroidism, should be excluded before surgery.

Consult with your physician for all specific criteria related to the above procedures.  Health Net has a designated network of bariatric surgical centers to perform weight loss surgery.  Your Member Physician can provide you with information about these centers.  You will be directed to a Health Net designated bariatric surgical center at the time authorizations is obtained.  If you live 50 miles or more from the nearest Health Net designated bariatric surgical center, you are eligible to receive travel expense reimbursement.  All requests for travel reimbursement must be prior approved by Health Net. 

• Insertion of internal prosthetic devices. See 5(a) – Orthopedic and prosthetic devices for device coverage information
• Treatment of burns

Note: For female surgical family planning procedures see Family Planning Section 5(a)
Note: For male surgical family planning procedures see Family Planning Section 5(a)

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

$20 per PCP visit, $30 per specialist visit

Nothing for surgery - $150 copayment per day up to 5 days per inpatient admission or $200 copayment for outpatient surgery

• Voluntary sterilization (e.g., Tubal ligation)

Nothing

• Voluntary sterilization (e.g., Vasectomy)

Nothing

Not covered:

• Reversal of voluntary sterilization
• Routine treatment of conditions of the foot; (see Foot care)

All charges

Medically necessary standard fertility preservation for iatrogenic infertility for adults and adolescents with a female reproduction system prior to commencing treatment that is likely to cause infertility (excluding voluntary sterilization):

1. Embryo cryopreservation;
2. Cryopreservation of mature oocytes;
3. Ovarian transposition (oophoropexy);
4. Radiation (gonadal) shielding;
5. Conservative gynecologic surgery including but not limited to the following:
   • Radical trachelectomy in early stage cervical cancer (i.e., stage IA2 to IB cervical cancer with diameter <2 cm and invasion <10 mm);
   • Ovarian cystectomy for early-stage ovarian cancer.

Medically necessary standard fertility preservation for iatrogenic infertility adults and adolescents with a male reproductive system prior to commencing treatment that is likely to cause infertility (excluding voluntary sterilization):

1. Cryopreservation of sperm;
2. Radiation (gonadal) shielding

Note: your pay cost-sharing for other services associated with fertility preservation for iatrogenic infertility, including:

• Lab, X-ray and other diagnostic services as described in Section 5(a)
• Outpatient hospital and ambulatory surgical centers as described in Section(b)
• Prescription drugs as described in Section 5(f)

$150 copayment per day up to 5 days per inpatient admission or $200 copayment for outpatient surgery

Not covered:

Coverage for fertility preservation does not include the following:

• Follow-up Assisted Reproductive Technologies (ART) to achieve future pregnancy such as artificial insemination, in vitro fertilization, and/or embryo transfer
• Pre-implantation genetic diagnosis
• Donor eggs, sperm or embryos
• Gestational carriers (surrogates)

All charges

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
  • the condition produced a major effect on the member’s appearance; and
  • the condition can reasonably be expected to be corrected by such surgery

• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; webbed fingers and toes.

 Nothing for surgery - $150 copayment per day up to 5 days per inpatient admission or $200 copay for outpatient surgery

• All stages of breast reconstruction surgery following a mastectomy, such as:
  • surgery to produce a symmetrical appearance of breasts;
  • treatment of any physical complications, such as lymphedemas;
  • breast prostheses and surgical bras and replacements (see Prosthetic devices)

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.

• Gender affirming surgery for the treatment of gender dysphoria/ gender identity disorder is subject to medical necessity and plan criteria must be met

Procedures are reviewed for medical necessity in alignment with Health Net’s medical policy and WPATH criteria.
Services covered:

• Hormone treatment
• Counseling
• Psychotherapy
• Hysterectomy
• Bilateral mastectomy
• Chest reconstruction or breast augmentation
• Facial feminization/facial plastic reconstruction
• Facial hair removal
• Genital reconstruction

Gender nonconformity refers to the extent to which a person’s gender identity, role, or expression differs from the cultural norms prescribed for people of a particular sex.
Gender dysphoria refers to the discomfort or distress that is cause by a discrepancy between a person’s gender identity and that person’s sex assigned at birth (and the
associated gender role and/or primary and secondary sex characteristics). Only some transsexual, transgender, and gender nonconforming people experience gender dysphoria at some point in their lives. 

Services for gender affirmation most often include hormone treatment, counseling psychotherapy, complete hysterectomy, bilateral mastectomy, chest reconstruction or augmentation as appropriate, genital reconstruction, facial hair removal, and certain facial plastic reconstruction. Not every individual will require each intervention so necessity needs to be considered on an individualized basis.  Eligible candidates must be 18 years old and above, exceptions to adolescent female to male patients under 18 years old is listed in the policy.  For Health Net’s full policy on gender affirming procedures, please visit www.healthnet.com/content/healthnet/en_us/providers/working with-hn/medical_policies.html#clinical_practice_guidelines

Nothing for surgery - $150 copayment per day up to 5 days per inpatient admission or $200 copay for outpatient surgery

Not covered:

• Cosmetic surgery – any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury.  

Oral surgical procedures, limited to:

• Reduction of fractures of the jaws or facial bones;
• Surgical correction of cleft lip, cleft palate or severe functional malocclusion;
• Removal of stones from salivary ducts;
• Excision of leukoplakia or malignancies;
• Excision of cysts and incision of abscesses when done as independent procedures; and
• Other surgical procedures that do not involve the teeth or their supporting structures.

All charges

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan.  Refer to Other services in Section 3 for prior authorization procedures.

Autologous pancreas islet cell transplant (as an adjunct to total or near total pancreatectomy) only for patients with chronic pancreatitis

• Cornea
• Heart
• Heart/lung
• Intestinal Transplant
  • Isolated small intestine
  • Small intestine with the liver
  • Small intestine with multiple organs, such as the liver, stomach, and pancreas

• Kidney
• Kidney-pancreas
• Liver  
• Lung:  single/bilateral/lobar
• Pancreas

These tandem blood or marrow cell transplants for covered transplants are subject to medical necessity review by the Plan.  Refer to Other services in Section 3 for prior authorization procedures.

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

Blood or marrow stem cell transplants

The plan extends coverage for the diagnoses as indicated below.

• Allogeneic transplants for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid leukemia
  • Advanced Hodgkins lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)
  • Advanced neuroblastoma
  • Advanced non-Hodgkins lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Infantile malignant osteoporosis
  • Kostmann's syndrome
  • Leukocyte adhesion deficiencies
  • Marrow failure and related disorders (i.e. Fanconi's PNH, Pure Red Cell Aplasis)
  • Mucolipidosis (e.g. Gaucher's disease, metachromatic leukodystrophy, adrenoleukodystrophy)
  • Mucopolysaccharidosis (e.g. Hurler's syndrome, Maroteaux-Lamy syndrome variants)
  • Myelodysplasia/Myelodyplastic syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Phagocytic/Hemophagocytic deficiency diseases (e.g. Wiskott-Aldrich syndrome)
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
  • Sickle cell anemia
  • X-linked lymphoproliferative syndrome
  • Hematopoietic stem cell transplant
• Autologous transplants for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis  
  • Breast Cancer
  • Ependymoblastoma
  • Epithelial ovarian cancer
  • Advanced Ewing's sarcoma (pediatric only)
  • Medulloblastoma
  • Multiple myeloma
  • Pineoblastoma
  • Neuroblastoma
  • Testicular, Mediastinal, Refroperitoneal, and Ovarian germ cell tumors
  • Hematopoietic stem cell transplant

Mini-transplants performed in a clinical trial setting (non-myeloablative, reduced intensity conditioning or RIC) for members with a diagnosis listed below are subject to medical necessity review by the Plan.

Refer to Other services in Section 3 for prior authorization procedures:

• Allogeneic transplants for
  • Acute Lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Acute myeloid  leukemia (when criteria is met)
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced Myeloproliferative Disorders (MPDs)(when criteria is met)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
  • Hemoglobinopathy
  • Marrow failure and related disorders (i.e. Fanconi's PNH, Pure Red Cell Aplasia)
  • Myelodysplasia/Myelodysplastic syndromes
  • Paroxysmal Nocturnal Hemoglobinuria
  • Severe combined immunodeficiency
  • Severe or very severe aplastic anemia
• Autologous transplants for
  • Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin's lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin's lymphoma with recurrence (relapsed)
  • Amyloidosis
  • Neuroblastoma

These blood or marrow stem cell transplants are covered only in a National Cancer Institute or National Institutes of health approved clinical trial or a Plan-designated center of excellence if approved by the Plan's medical director in accordance with the Plan's protocols.  

If you are a participant in a clinical trial, the Plan will provide benefits for related routine care that is medically necessary (such as doctor visits, lab tests, X-rays and scans, and hospitalization related to treating the patient's condition) if it is not provided by the clinical trial.  Section 9 has additional information on costs related to clinical trials.  We encourage you to contact the Plan to discuss specific services if you participate in a clinical trial.

• Allogeneic transplants for
  • Advanced Hodgkin's lymphoma
  • Advanced non-Hodgkin's lymphoma
  • Beta Thalassemia Major
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Sickle Cell anemia
• Mini-transplants (non-myeloblative allogeneic, reduced intensity conditioning or RIC) for
  • Acute lymphocytic or non-lymphocytic (i.e. myelogenous) leukemia
  • Advanced Hodgkin's lymphoma
  • Advanced non-Hodgkin's lymphoma
  • Breast cancer
  • Chronic lymphocytic leukemia
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Colon cancer
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Myelodysplasia/Myelodyplastic syndromes
  • Myeloproliferative disorders (MPDs)
  • Non-small cell lung cancer
  • Ovarian cancer
  • Prostate cancer
  • Renal cell carcinomas
  • Sarcomas
  • Sickle cell anemia
• Autologous Transplants for
  • Advanced childhood kidney cancers
  • Advanced Ewing sarcoma (pediatric only)
  • Advanced Hodgkin's lymphoma
  • Advanced non-Hodgkin's lymphoma
  • Aggressive non-Hodgkin's lymphoma
  • Breast cancer
  • Childhood rhabdomyosarcoma
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Epithelial Ovarian Cancer
  • Mantle Cell (Non-Hodgkin lymphoma) (adults only)
  • Small cell lung cancer
  • Systemic lupus erythematosus
  • Systemic sclerosis

Note:  We cover related medical and hospital expenses of the donor when we cover the recipient.  We cover donor testing for the actual solid organ donor or up to four bone marrow/stem cell transplant donors in addition to the testing of family members.

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

Room and board, such as

• Ward, 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 pay the additional charge above the semiprivate room rate.

Other hospital services and supplies, such as:

• Operating, recovery, maternity, 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
• Take-home items
• Medical supplies, appliances, medical equipment, and any covered items billed by a hospital for use at home

Not covered:

• Custodial care
• Non-covered facilities, such as nursing homes, schools
• Personal comfort items, such as phone, television, barber services, guest meals and beds
• Private nursing care

All charges

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medicines
• 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.

Nothing

Extended care/Skilled nursing facility (SNF): Up to 100 days per calendar year for services such as:

• Bed, board and general nursing care
• Drugs, biologicals, supplies and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan physician

Not covered:  Custodial care and personal comfort items such as phone and television   

Hospice care: Up to 210 days for services such as:

• Inpatient and outpatient care
• Family counseling

The Plan has a comprehensive program for end of life care.  the program makes available

• Durable Power of Attorney for healthcare
• Addresses financial counseling
• Includes legal counseling 
• Addresses caregiver needs
• Includes bereavement counseling for many members

Note: This program is based on Medicare guidelines for hospice coverage, and the Plan contracts with open access hospice programs that allow medical services not limited to palliative care.

Nothing

• Emergency care at a doctor’s office
• Emergency care at an urgent care center

$20 per visit

• Emergency care at an emergency room
• Emergency care as an outpatient or inpatient at a hospital, including doctors’ services

• Emergency care at a doctor’s office
• Emergency care at an urgent care center

• Emergency care at an emergency room
• Emergency care as an outpatient or inpatient at a hospital, including doctors’ services

Not covered:

• Elective care or non-emergency care
• Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
• Follow-up care not authorized by your participating physician group

All charges

Professional ground and air ambulance service when medically appropriate.

If we approve part or all of a treatment plan, we cover professional services by licensed professional mental health and substance use disorder treatment practitioners as long as they act within the scope of their license.  This includes psychiatrists, psychologists, clinical social workers, licensed professional counselors, and marriage and family therapists.

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

• Diagnostic evaluation
• Crisis intervention and stabilization for acute episodes
• Medication evaluation and management
• Psychological and neuropsychological testing when necessary to determine the appropriate psychiatric treatment
• Treatment and counseling (including individual or group therapy visits)
• Diagnosis and treatment of substance use disorders, including detoxification, treatment and counseling by licensed practitioners. 
• Professional charges for intensive outpatient treatment in a provider’s office or other professional setting
• Electroconvulsive therapy

• Outpatient diagnostic tests provided and billed by a licensed mental health and substance use disorder treatment practitioner

• Outpatient diagnostic tests provided and billed by a laboratory, hospital or other covered facility

No charge for laboratory, X-ray and other diagnostic tests.

See Section 5(c) for facility charges

• Inpatient diagnostic tests provided and billed by a hospital or other covered facility

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

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

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

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

Nothing

The Mental Health and Substance Use Disorder benefits are administered by Health Net Behavioral Health. When you need to see a Participating Mental Health Professional, contact the Behavioral Health Administrator by calling the Health Net Customer Contact Center at the phone number on your Health Net I.D. card.

Certain services and supplies for Mental Health and Substance Use Disorder require prior authorization by the Behavioral Health Administrator to be covered. The services and supplies that require prior authorization are:

• Outpatient procedures that are not part of an office visit (for example: psychological and neuropsychological testing, outpatient electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS), outpatient detoxification, partial hospitalization, day treatment, half-day partial hospitalization and 23-hour outpatient observation; and
• Inpatient, residential, partial hospitalization, inpatient ECT, Inpatient psychological and neuropsychological testing and;
• Behavioral health treatment for Autism (see below under “Outpatient Services”).

No prior authorization is required for outpatient office visits.

We will provide medical review criteria or reasons for treatment plan denials to enrollees, members or providers upon request or as otherwise required.

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.

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

• Drugs and medicines that by Federal law of the United States require a physician’s prescription for their purchase, except those listed as Not covered.
• Insulin
• Diabetic supplies limited to (specific brands apply):
  • blood glucose monitoring strips, Ketone test strips and lancet

  • Disposable needles and syringes for the administration of covered medications

• Drugs for sexual dysfunction (see limits listed in the Drug List)
• Drugs to treat gender dysphoria

For Health Net’s full policy on gender affirming procedures, please visit www.healthnet.com/content/healthnet/en_us/providers/working-with-hn/medical_policies.html#clinical_practice_guidelines

For drugs filled at a Plan pharmacy:

$10 for generic drugs

$35 for brand drugs

$60 for non-formulary drugs

20% to a maximum of $200 per prescription for specialty drugs

For drugs filled through the mail order program:

$20 for generic drugs

$70 for brand drugs

$120 for non-formulary drugs

Note: If there is no generic equivalent available, you will still have to pay the brand name copay

Medications prescribed to treat obesity.

Appetite suppressants and drugs for body weight reduction require a prescription in order to be dispensed for the treatment of obesity are covered when Medically Necessary for the treatment of morbid obesity or when you meet Health Net Prior Authorization coverage requirements. The prescribing Physician must request and obtain Prior Authorization for coverage.

Saxenda (self-injectable) is covered with prior authorization approval.
Wegovy (self-injectable) is covered with prior authorization approval.

Oral anti-obesity medications that are in the Health Net Preferred Drug list include Qsymia, Contrave, Orlistat, Phentemine are covered with prior authorization.

50% of charges

Contraceptive drugs and devices as listed in the Health Resources and Services Administration site https://www.hrsa.gov/womens-guidelines.

Contraceptive coverage is available at no cost to FEHB members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories 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. 

• Over-the-counter and prescription drugs approved by the FDA to prevent unintended pregnancy.
• Note: The "morning after pill" is an over-the-counter emergency contraceptive drug. It is considered a preventive service under contraceptives, with no cost to the member if prescribed by a physician and purchased at a network pharmacy.  If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.
  • Use the contraception exception process if the contraception recommended by your provider is not covered or has an out-of-pocket cost. You or your provider may submit an exception request.
  • Members can call the Customer Contact Center at 1-800-522-0088 to submit an exception request
• Reimbursement for covered over-the-counter contraceptives can be submitted in accordance with Section 7.

For additional Family Planning benefits see Section 5(a)

No charge

NOTE: Over-the-counter and appropriate prescription drugs approved by the FDA to treat tobacco dependence are covered under the Tobacco Cessation Education Classes and Programs in Section 5(a)

See Section 5(a)

Not covered

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Fertility drugs (for non-covered fertility services)
• Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies 
• Non-prescription medications unless specifically indicated elsewhere

All charges

Opioid rescue agents such as naloxone are covered under this Plan with no cost sharing when obtained from a network pharmacy in any over-the-counter or prescription form available such as nasal sprays and intramuscular injections.

For more information consult the FDA guidance at https://www.fda.gov/consumers/consumer-updates/access-naloxone-can-save-life-during-opioid-overdose

Or call SAMHSA’s National Helpline 1-800-662-HELP (4357) or go to https://www.findtreatment.samhsa.gov/.

Nothing

Limited benefits:

• Drugs for sexual dysfunction are limited to 2 doses per week or 8 tablets per month

Fertility drugs associated with covered services under the diagnosis and treatment of infertility are covered services under the diagnosis and treatment of infertility are covered under the Medical Services and Supplies Benefits (see page 35).

The following are covered:

Preventive Medications with USPSTF A and B recommendations. These may include some over-the-counter vitamins, nicotine replacement medications, and low dose aspirin for certain patients.  For current recommendations go to www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations

Not covered:

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Fertility drugs
• Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies
• Nonprescription medications

All charges

Not covered:

All charges

Under the flexible benefits option, we determine the most effective way to provide services.

• We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative. If we identify a less costly alternative, we will ask you to sign an alternative benefits agreement that will include all of the following terms in addition to other terms as necessary.  Until you sign and return the agreement, regular contract benefits will continue.
• Alternative benefits will be made available for a limited time period and are subject to our ongoing review.  You must cooperate with the review process.
• By approving an alternative benefit, we do not guarantee you will get it in the future.
• The decision to offer an alternative benefit is solely ours, and except as expressly provided in the agreement, we may withdraw it at any time and resume regular contract benefits.
• If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change).  You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request.
• Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process.  However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claim process (See Section 8).

• Health Net's Wellness Programs address the health needs of the whole person from wellness health coaching to chronic condition management.
  
  • Members can take a RealAge Test which provides a personalized report of the individual's behavioral and medical health risks.
  • Receive timely access through the Nurse Advice Line for help with everyday health questions 24/7.
  • Craving to Quit is our tobacco cessation program that allows members to talk with a quit coach for encouragement and support and offers a personalized plan to quit.
  • Start Smart for Your Baby (SSFB)is a program for pregnant and new parents, providing custom support and care for a healthy pregnancy and baby.

For more information on our Wellness Programs, members can call the Customer Service number found on the back of the member ID card or go to www.healthnet.com/fehb and click on "Health and Wellness.”

The Start Smart for Your Baby (SSFB) program incorporates the concepts of care management, care coordination, and disease management in an effort to improve the health of pregnant people and their newborns. The program’s multi-faceted approach to improving prenatal and postpartum care includes enhanced member outreach and incentives, wellness materials, intensive care management, and support of the appropriate use of medical resources to extend the gestational period and reduce the risks of pregnancy complications, premature delivery, and infant disease. Self-measured blood pressure cuff is covered for members that are diagnosed with hypertension, pregnancy induced hypertension or preeclampsia. For more information, please visit our website at www.healthnet.com/fehb or contact us at 800-522-0088.

The Program provides:

One visit with a doula to get to know each other.

• Up to eight visits that can happen during the pregnancy and postpartum.
• Support during labor and birth*
• Up to two-three-hour postpartum visits after the end of a pregnancy.

*This would also apply to stillborn, miscarriage, or abortion.

For more information on our Wellness Programs,   members can call the Customer Service number found on the back of the member ID card or go towww.healthnet.com/fehb and click on "Health and Wellness.”

Active and Fit Direct program offers fitness center membership to 12,700+ fitness centers nationwide for just $28 a month (plus a one-time $28 enrollment fee).  For more information, please visit our website at www.healthnet.com/fehb or contact us at 800-522-0088.

Please contact our Telecommunications Device for the Deaf at 800-995-0852.

Health Net has affordable healthcare plans members can depend on. We offer a wide range of competitively-priced plans with the benefits your dependents are looking for. Members can also take advantage of our Wellness Center® a free series of tools and services to help you manage and support your well-being.

For more information on Health Net Individual and Family plans go to www.healthnet.com and click on Shoppers or call Health Net at 800-909-3447.

In most cases, providers and facilities file claims for you. Providers must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. For claims questions and assistance, contact us at 800-522-0088, or at our Website
www.healthnet.com/fehb.

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

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

Note:  Canceled checks, cash register receipts, or balance due statements are not acceptable substitutes for itemized bills.

Submit your claims to:

Health Net of California, Commercial Claims, P.O. Box 9040, Farmington, MO 63640-9040

When you purchase a prescription drug, and your Plan ID card is not available, eligibility cannot be determined, or the prescription is for a medical emergency outside of California, you must pay for the drug when it is dispensed, and file a claim for reimbursement. For claims questions and assistance, or to request a prescription drug claim form call us at 800-522-0088.

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

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 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 processed in Section 8 of this brochure.

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

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

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

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: Health Net of California, P.O. Box 10348, Van Nuys, CA 91410-0348; and

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

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

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

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

1. Pay the claim or
2. Write to you and maintain our denial or
3. 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 to OPM at:  United States Office of Personnel Management, Healthcare and Insurance, Federal Employees Insurance Operations, FEHB 3, 1900 E Street, NW, Washington, DC 20415-3630.

Send OPM the following information:

• A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
• Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
• Copies of all letters you sent to us about the claim;
• Copies of all letters we sent to you about the claim; and
• Your daytime phone number and the best time to call.
• Your email address, if you would like to receive OPM's decision via email.  Please note that by providing your email address, you may receive OPM's decision more quickly.

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

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

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

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

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

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

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

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

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

When we are the secondary payor, we will determine our allowance. After the primary plan 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 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 proceeding that is based on a claim you filed under OWCP or similar laws.

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

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

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

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

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 whole” or fully compensated for the full amount of damages claimed.

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

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

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

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

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

• Routine care costs - costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient's condition, whether the patient is in a clinical trial or is receiving standard therapy. 
• 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. Your care must continue to be authorized by your Plan physician.

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 800-522-0088 or see our website at www.healthnet.com/fehb.

We do not waive any costs on the High Option if the Original Medicare Plan is your primary payor:

Deductible
You pay without Medicare- (High Option): N/A - No deductible
You pay with Medicare Part B - (High Option):  N/A - No deductible 

Out-of-Pocket Maximum
You pay without Medicare- (High Option): $1,500 Self Only/$3,000 Self Plus One/$4,500 Self and Family
You pay with Medicare Part B - (High Option): $1,500 Self Only/$3,000 Self Plus One/$4,500 Self and Family

Part B Premium Reimbursement Offered 
You pay without Medicare- (High Option): N/A 
You pay with Medicare Part B - (High Option):  N/A

Primary Care Provider
You pay without Medicare- (High Option): $20 copay
You pay with Medicare Part B - (High Option): $20 copay

Specialist
You pay without Medicare- (High Option): $30 copay
You pay with Medicare Part B - (High Option): $30 copay

Inpatient Hospital
You pay without Medicare- (High Option): $150/per day (5 day max copay)
You pay with Medicare Part B - (High Option):  $150/per day (5 day max copay)

Outpatient Surgery - Hospital
You pay without Medicare- (High Option): $200 copay
You pay with Medicare Part B - (High Option):  $200 copay

Incentives Offered 
You pay without Medicare- (High Option): N/A 
You pay with Medicare Part B - (High Option): N/A

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefit 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:

We offer a plan that will offer lower office visit copayments, urgent care and emergency care, plus additional coverage for additional benefits such as dental and the Silver and Fit Fitness program. You may enroll in the plan if:

• You enroll in the Plan’s High Option
• You enroll in Seniority Plus for Federal Members
• The FEHB subscriber completes an additional application for enrollment in Seniority
  Plus

For more information on our Medicare Advantage Seniority Plus, please contact us at 800-275-4737.

Deductible
You pay without Medicare- (High Option): N/A - No deductible
You pay with Health Net Medicare Advantage Seniority Plus: N/A - No deductible

Out-of-Pocket Maximum
You pay without Medicare- (High Option): $1,500 Self Only/$3,000 Self Plus One/$4,500 Self and Family
You pay with Health Net Medicare Advantage Seniority Plus: $3,400 for Self Only

Part B Premium Reimbursement Offered
You pay without Medicare- (High Option): N/A
You pay with Health Net Medicare Advantage Seniority Plus: No

Primary Care Physician
You pay without Medicare- (High Option): $20 copay
You pay with Health Net Medicare Advantage Seniority Plus: $5 copay

Specialist
You pay without Medicare- (High Option): $30 copay
You pay with Health Net Medicare Advantage Seniority Plus: $5 copay

Inpatient Hospital
You pay without Medicare- (High Option): $150/per day (5 day max copay)
You pay with Health Net Medicare Advantage Seniority Plus: $0 copay

Outpatient Surgery - Hospital
You pay without Medicare- (High Option): $200 copay
You pay with Health Net Medicare Advantage Seniority Plus: $0 copay

Incentives Offered
You pay without Medicare- (High Option): N/A
You pay with Health Net Medicare Advantage Seniority Plus: This plan includes Dental and Vision benefits. It also offers Silver and Fit Fitness program at no cost to you.

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

Suspended FEHB coverage to enroll in a Medicare Advantage plan:
If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in a Medicare Advantage plan, eliminating your FEHB premium. (OPM does not contribute to your Medicare Advantage plan premium.) For more information on suspending your FEHB enrollment, contact your retirement or employing office. If you later want to reenroll 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.

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

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

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

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

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

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

• Medicare was the primary payor before eligibility due to ESRD

• Medicare based on age and disability

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

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

An 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.
• 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.

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

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

See Section 4, page 22

See Section 4, page 22

See Section 4, page 22

See Section 4, page 22

Experimental or investigational services are services that are not widely accepted or recognized within the organized medical community as standards of care. Our Medical Policy Committee determines what procedures and services are experimental/investigational using published peer review medical and surgical literature. The procedure or service will be evaluated based on its health effects, safety, quality and cost effectiveness. In some cases, we use an independent medical review for expert evaluation and determination of coverage.

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

Infertility exists when any of the following apply to a Member:

• The Member is a female (or individual with female reproductive organs) that has been unable to conceive pregnancy after 1 year of regular unprotected sex when under 35 years of age, or 6 months when age 35 and older, or when a pregnancy did occur, a live birth was not achieved; OR
• The Member has been unable to conceive pregnancy through attempted egg-sperm contact via artificial insemination; OR
• A licensed physician’s determination of infertility, based on the Member's medical, sexual, and reproductive history, age, physical findings, diagnostic testing, or any combination of those factors.

Medical necessity is the criteria used by us and the participating physician group to provide covered services in the prevention, diagnosis, and treatment of your illness or condition. Determination of whether services or supplies are medically necessary will be made according to procedures we and the participating physician group have established. Medically necessary services are determined to be:

• Not experimental or investigational
• Appropriate and necessary for the symptoms, diagnosis, or treatment of a condition, illness or injury
• Provided for the diagnosis or care and treatment of the condition, illness or injury
• Not primarily for the convenience of the member, member’s physician, or anyone else
• The most appropriate supply or level that can safely be provided. For example, outpatient rather than inpatient surgery may be authorized when the setting is safe and adequate.

Primary care provider office visit

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.

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.

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

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

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

Urgent care claims usually involve Pre-service  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 800-522-0088.  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.

$20 primary care; $30 specialist

27

$150 per day up to 5 days per admission copay

54

$200 copay

55

$100 per visit (waived if admitted to Hospital)

58

$100 per visit (waived if admitted to Hospital)

58

Regular cost-sharing

59

$10 copay for a 30-day supply of formulary generic drugs - $20 for a 90-day supply through mail order.

$35 copay for a 30-day supply of formulary brand name drugs - $70 for a 90-day supply through mail order.

$60 copay for a 30-day supply of non-formulary drugs - $120 for a 90-day supply through mail order.

20% to a maximum of $200 per prescription for specialty drugs - not available through mail order.

62

$20 PCP office visit; $30 specialist visit; $100 Emergency Room

66

$20 PCP office visit, $30 specialist visit

38

Services for the deaf and hearing impaired, Centers of Excellence, Decision Power, Active & Fit Direct program

67

Nothing after $1,500/Self Only, $3,000/Self Plus One or $4,500/Self and Family enrollment per year.  

For prescriptions Nothing after $2,900/Self Only, $5,800/Self Plus One or $8,700/Family enrollment per year.

22