• No pre-existing condition limitation

• Minimum essential coverage (MEC)

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

• Minimum value standard

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

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

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

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

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

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

• Types of coverage available for you and your family

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

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31-days before to 60-days after that event. The Self Plus One or Self and Family enrollment begins on the first day of the pay period in which the child is born or becomes an eligible family member. When you change to Self Plus One or Self 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 are married.  A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s FEHB enrollment.

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

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

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

• Family Member Coverage

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

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

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

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

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

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

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

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

• Children’s Equity Act

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

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

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

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

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

• When benefits and premiums start

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

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

• When you retire

• When FEHB coverage ends

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

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

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

• Upon divorce

If you are divorced from a Federal employee or annuitant, you may not continue to get benefits under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get information about your coverage choices. You can also visit OPM’s Web site, www.opm.gov/healthcare-insurance/healthcare/plan-information/.  A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment. 

• Temporary Continuation of Coverage (TCC)

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

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

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

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

• Converting to individual coverage

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

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

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

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, waiting period will not be imposed, and your coverage will not be limited due to pre-existing conditions. When you contact us we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act’s Health Insurance Marketplace in your state. For assistance in finding coverage, please contact us at  877-835-9861 or visit our website at www.uhcfeds.com.

• Health Insurance Market Place

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.

Identification cards

We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation letter (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 1-877-835-9861, or write to us at UnitedHealthcare Insurance Company, Federal Employee Health Benefits (FEHBP Program at P.O. 30432, Salt Lake City, UT 84130-0432  You may also print temporary cards and request replacement cards through our web site www.myuhc.com.

Where you get covered care

Plan providers

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

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

Plan facilities

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

What you must do to get covered care

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

Primary care

Your primary care physician will provide most of your health care, or give you a referral to see a specialist. If you want to change primary care physicians or if your primary care physician leaves the Plan, call us.  We will help you select a new one.

Specialty care

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

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

• If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. 
  
  Your primary care physician will create your treatment plan.  The physician may have to get an authorization or approval from us beforehand.  If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician.  If he or she decides to refer you to a specialist, ask if you can see your current specialist.

• If your current specialist does not participate with us, you must receive treatment from a specialist who does.  Generally, we will not pay for you to see a specialist who does not participate with our Plan.

• If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.
• If you have a chronic and disabling condition and lose access to your specialist because we:
  • terminate our contract with your specialist for other than cause;
  • drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB program plan; or
  • reduce our service area and you enroll in another FEHB plan;

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

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

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

• If you are hospitalized when your enrollment begins

We pay for covered services from the effective date of your enrollment.  However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 1-877-835-9861.  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.

You need prior Plan approval for certain services

Since your provider schedules most procedures and inpatient hospitalization, the pre-service claim approval process applies to care shown under Other services.

“You must get prior approval for certain services. Failure to do so will result in a penalty. 

• Inpatient Hospital Admission

• Other Services

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

• Ambulance-Non-emergency
• Angioma/Hemangioma (with pictures)
• Applied Behavioral Analysis (ABA)
• Bariatric Surgery
• Blepharoplasty (with pictures)
• Breast implant, removal, breast reconstruction for non-cancer diagnosis, breast reduction
• Computed Tomography (CT scans)
• Dental procedures in a facility
• Durable medical equipment over $1,000
• Clinical Trials
• Coronary Artery bypass
• Congenital anomaly repair
• Dialysis
• Genetic testing
• Gender reassignment surgical procedures
• Gynecomastia surgery
• Hysterectomy
• Human Growth Hormone
• Implanted spinal cord stimulators
• Inpatient hospitalization
• Intensive Outpatient treatment
• Joint replacement
• Magnetic resonance angiogram and imaging ( MRA) (MRI)
• PET scans ( non-cancer diagnosis)
• Partial Day Treatment
• Pulmonary rehabilitation 
• Radiation therapy
• Reconstructive Surgery
• Sclerotherapy
• Sleep apnea surgery and attended sleep studies ( Polysomnograms)
• Substance abuse disorder treatment
• Some therapies (physical, occupational, speech) after 8th visit
• Transplants
• Uvulopalatopharyngoplasty
• Vein ablation
• Vagus nerve 
• Ventricular assist device

Plan providers are notified of all prior authorization/preauthorization requirements. In addition, your admitting physician and facility must also preauthorize any elective inpatient stays.

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

First, your physician, your hospital, you, or your representative, must call us at 1-877-835-9861 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.

• Non-urgent care claims

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

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

• Urgent care claims

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

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

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

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM.  Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 877-835-9861.  You may also call OPM’s Health Insurance 3 at 202 606-0737 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review.  We will cooperate with OPM so they can quickly review your claim on appeal.  In addition, if you did not indicate that your claim was a claim for urgent care, call us at 877-835-9861. If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

• Concurrent care claims

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

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

The Federal Flexible Spending Account Program – FSAFEDS

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

• Emergency inpatient admission

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

• Maternity Care

Further, if your baby stays after you are discharged, then your physician or the hospital must contact us for precertification of additional days for your baby.    When a newborn requires definitive treatment during or after the mother's confinement, the newborn is considered a patient in his/her own right. If the newborn is eligible for coverage , regular medical or surgical benefits apply rather than maternity benefits.

• If your treatment needs to be extended

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

What happens when you do not follow the precertification rules when using non-network facilities

This plan does not offer coverage for non-network facilities or providers.  If you use non-network facilities or see non network providers without written authorization from the plan, you will be responsible for 100% of the charges.

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.

• To reconsider a non-urgent care claim

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

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

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

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

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

3.  Write to you and maintain our denial.

• To reconsider an urgent care claim

In the case of an appeal of a pre-service urgent care claim, within 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.

• To file an appeal with OPM

Copayments

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

Deductible

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

• The calendar year deductible is $2,000 per person. Under a Self Only enrollment, the deductible is considered satisfied and benefits are payable for you when your covered expenses applied to the calendar year deductible for your enrollment reach $2,000. Under a Self Plus One enrollment, the deductible is considered satisfied and benefits are payable for you and one other eligible family member when the combined covered expenses applied to the calendar year deductible for your enrollment reach $4,000. Under a Self and Family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $4,000. 

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

If you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the deductible of your new option

Coinsurance

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

Example: In our Plan, you pay 30% of our allowance for physician services and durable medical equipment.

Differences between our Plan allowance and the bill

Network providers agree to accept our Plan allowance so if you use a network provider, you never have to pay the difference between our Plan allowance and the billed amount for covered services.

Your catastrophic protection out-of-pocket maximum

After your (copayments and coinsurance) total $7,350 for Self Only or $7,350 per person for Self Plus One, or $14,700 per Self and Family enrollment in any calendar year, you do not have to pay any more for covered services.  However, copayments or coinsurance for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments for these services: expenses for services or supplies that exceed the stated maximum dollar limit or day limit, charges for non-covered services and any penalties for failure to obtain preauthorization. 

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

Carryover

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

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

Medical Services Provided by Physician: Routine Preventive Care provided in-network

Nothing - covered at 100%

Not Subject to deductible

Medical Services Provided by Physician: Diagnostic and treatment services provided in the office

Primary Care Physician: 30% coinsurance

Specialist: 30% coinsurance

Urgent care services 

30% coinsurance

Telehealth - Virtual visits provided by Doctor on Demand, American Well and Teladoc

30% coinsurance

Laboratory, X-ray and Diagnostic Tests

30% coinsurance

Services Provided by a hospital: Inpatient 

30% coinsurance

Services Provided by a hospital: Outpatient Surgical

30% coinsurance

Emergency Benefits: Emergency Room 

30% coinsurance waived if admitted

Emergency Benefits: Ambulance services

30% coinsurance 

Mental Health and Substance Abuse

30% coinsurance

Prescription Drugs

30-Day supply at Retail:

Tier 1: $15; Tier 2: $45; Tier 3: $85; Tier 4: $200

90-Day supply at Mail Order:

Tier 1: $45; Tier 2: $135; Tier 3: $225; Tier 4: $600

Deductible

No deductible for this Medicare plan

• Primary Care Physician (PCP) visit

$0 copayment

• Specialist visit

$0 copayment

• Routine annual physical

$0 copayment

• Virtual doctor visits

$0 copayment

• Outpatient Rehabilitation - physical, occupational or speech/language therapy

$0 copayment

• Urgent care center

$0 copayment

Hospital services: Inpatient hospital

$0 copayment

Hospital services:  Inpatient mental health

$0 copayment

Hospital services:  Skilled Nursing Facility

$0 copay per day days 1-20

$0 copay per additional day up to 100 days

Hospital services:  Emergency Room

$0 copayment

Hospital services:  Ambulance

$0 copayment

Diagnostic Services

$0 copayment

Hearing Aids

Plan pays up to $500 every 3 years

Pharmacy benefits 

30-day supply:

Tier 1: $7, Tier 2: $35, Tier 3: $65, Tier 4: $100

90-day supply at mail order:

Tier 1:$14, Tier 2: $70, Tier 3: $130, Tier 4: $200

UnitedHealthcare  app

At home and on the go our digital resources can help you manage health and finances. You want to have the resources to make well informed financial and health care decisions. UnitedHealthcare has created tools to help members maximize their benefits.

At UnitedHealthcare, our mission is helping people live healthier lives®. We strive to make health care simpler and easier for you to understand with our suite of integrated consumer tools on myuhc.com®. For members who are on the go, digital resources are available on the UnitedHealthcare app — wherever and whenever they need to manage your health care.

Download the UnitedHealthcare app* for access to health plan ID cards, benefits information and help answering questions.

• The mobile app is designed to help you manage different aspects of your health, like searching for providers and getting health care cost estimates for specific treatments and procedures. 
• Members have access to their health plan ID card, claims information and real-time status on account balances, deductibles and out-of-pocket spending. 
• With the UnitedHealthcare app, you can manage the health care for your entire family, 24/7. They can find a physician or facility near them using the GPS location search feature. 
• The UnitedHealthcare app is the go-to resource to help you manage your health care. Anywhere. Anytime. 
• Members can find and receive care, access financial accounts, view claims status, estimate costs and pay bills directly from the app.  Available from the Apple Store or Google play

Online web portal can assist to Find Care and Costs to help you find and price care, at the same time. Located on myuhc.com, members can:   

• Find a quality doctor, clinic, hospital or lab that helps meet their needs.
• Use multiple search options to filter results by location, specialty, quality, cost, services offered and more.
• See provider ratings created by patients. 
• Review cost and care options before making an appointment to help control spending and choose the right level of service. 
• Access personalized cost and provider information specific to the benefit plan

*Download the UnitedHealthcare app from the App Store® or Google Play™

Quit for Life ®

Quit for Life provides our members with resources and support for tobacco cessation. Included are:

• Portal and mobile app
• Online learning with interactive and personalized content and a community support forum
• Integrated online and telephonic experience
• Live coaching sessions with coaches with degrees in counseling, addiction studies, and related fields
• Nicotine replacement therapy counseling
• 24/7 support for easier access to services
• Nicotine replacement therapy both prescription medications and over the counter products (with prescription)

Get started today. Go to myuhc.com, visit the "Health Resources" tab on the top right, Choose the "Quit for Life" tile. For Medicare Advantage members please contact the number on your UnitedHealthcare Medicare Advantage Card. 

Maternity Support Program

If you are thinking about having a baby or are expecting, the Maternity Support Program allows UnitedHealthcare® members the opportunity to build a longer-term relationship with a nurse.

After you enroll, you will be able to work directly with an experienced maternity nurse who is available to answer your questions and help you with things like:

Staying Connected

• Click to call a registered nurse 24/7
• Access personalized pregnancy information and content
• Link to your pregnancy benefits and cost estimator tools

Staying Healthy

• Monitor your pregnancy with a weight tracker
• Set reminders to take vitamins
• Keep track of calendar appointments and user-specified events
• Take health assessments, with the ability to consult a maternity program nurse by phone

Staying More Informed

• Read weekly developments that typically occur throughout your pregnancy
• Search symptoms and concerns that may arise during your pregnancy
• Track your baby’s movements with a kick counter

To get started you can reach us online https://phs.com/maternity or by phone 1-877-201-5328, TTY 711, 24 hours a day 7 days a week. Enroll in the Maternity Support Program by calling or downloading the app (Available for iPhone in Apple Store or Android in Google Play) and completing a Welcome Pregnancy Questionnaire where you can access maternity support. Like the app, it’s provided at no extra cost as part of your benefit plan.

Spine and Joint Program

Our Spine and Joint Program provides access to surgeons and expert facilities that qualify for our Center of Excellence (COE) designation. Facilities, surgeons and teams are independently evaluated and have been vetted by the NCQA-accredited Optum Clinical Sciences Institute and effective management of complex but common procedures.

• Care delivered at facilities with lower risk of readmissions and
• Predictable medical
• Support from a Centers of Excellence care navigator while a facility patient

 This program helps support our members while ensuring overall better experience and recovery. Members can experience reduced out of pocket costs when participating in the Spine and Joint Program.

UnitedHealth Premium

Choosing a doctor is one of the most important health decisions you’ll make. The UnitedHealth Premium® program can help you find doctors who are right for you and your family. You can find quality, cost-efficient care. Studies show that people who actively engage in their health care decisions have fewer Hospitalizations, fewer emergency visits, higher utilization of preventive care and overall lower medical costs.

The program evaluates physicians in various specialties using evidence-based medicine and national standardized measures to help you locate quality and cost-efficient providers. It’s easy to find a UnitedHealth Premium Care Physician. Just go to myuhc.com® and click on Find a Doctor. Choose smart. Look for blue hearts.

• Premium Care Physician meets UnitedHealth Premium program quality & cost-efficient care criteria.
• Quality Care Physician meets UnitedHealth Premium program quality care criteria, but does not meet the program’s cost-efficient care criteria or is not evaluated for cost-efficient care. Physician is not eligible for a Premium designation
• Not Evaluated for Premium Care physician’s specialty is not evaluated and/or does not have enough claims data for program evaluation or the physician’s program evaluation is in process

Real Appeal

Real Appeal® provides tools and support to help members lose weight and prevent weight-related health conditions. Real Appeal is provided at no additional cost to eligible FEHB members as part of your medical benefit plan. Medicare Advantage Members please refer to Real Appeal for Medicare Advantage members on the next page.  

The program can help motivate members to improve their health and reduce risk of developing costly, chronic conditions like cardiovascular disease and diabetes. The program combines clinically proven science with engaging content that teaches members how to eat healthier and be active, without turning their lives upside down, to help them achieve and maintain their weight-loss goals.

Real Appeal includes:

A Success Kit - After attending their first group coaching session, members receive a Success Kit with tools to help them kick-start their weight loss. The kit includes:

• Nutrition guide with recipes
• Portion plate
• Electronic food scale
• Digital weight scale
• Fitness guide
• 12 fitness DVDs
• Resistance bands

After 8 weeks of the program members receive a blender before the class on healthy smoothie options.

A personalized Transformation Coach - Coaches guide members through the program step-by-step, customizing it to help fit their needs, personal preferences, goals and medical history.

24/7 online support and mobile app - Staying accountable to goals may be easier than ever.

• Customizable food, activity, weight and goal trackers 
• Unlimited access to digital
• Success group support, which lets employees chat with others who are doing the Real Appeal program.
• Online TV shows that is fun, engaging and helps members learn new ways to be healthier

Why Real Appeal works - Real Appeal is guided by a Clinical Advisory Board of obesity, nutrition and behavior change experts that create customized content to help keep members engaged throughout their weight-loss journey. Members will learn steps to help with long-term transformation, which may translate to a happier, healthier member.

Specialty Pharmacy

Appropriate use of specialty medications can be important to maintaining or improving your health and your quality of life. Our specialty program provides the resources and personalized, condition-specific support you need to help you better manage your condition. These specialty medications are used to treat complex long-term conditions that require additional care and support. It may be injected, inhaled or taken by mouth. In addition, they may require additional education and support for best management, have unique storage or shipping requirements and may not be available at retail pharmacies.

The OptumRx® Specialty Services and BriovaRx Infusion Services, offers support to help you manage these conditions. Take advantage of personalized support - at no charge to you - from knowledgeable pharmacies and nurses who specialize in your condition. In addition you will receive:

• Access to your medications at the lowest cost
• Pharmacists available 24/7
• Support through clinical and adherence programs
• Any medication-related supplies at no additional cost
• Proactive refill reminders
• Timely delivery and shipping in confidential, temperature-sensitive packaging

 Contact 1-877-835-9861 or contact Briova directly at 1-855-4BRIOVA (1-855-427-4682)

Flexible Benefits Option

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

• We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative benefit. 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. Until you sign and return the agreement, regular contract benefits will
• Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review
• By approving an alternative benefit, we cannot guarantee you will get it in the
• 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
• 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 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 claims process (see Section 8).

Fitness Program

for Medicare Advantage Members:

Renew Active is a fitness benefit which is included in the Medicare Advantage plan which provides:

• A free gym membership to participating facilities 
  • To view participating facilities, please visit www.uhcrenewactive.com 
• Access to an extensive network of gyms and fitness locations near members
• A personalized fitness plan 
• Access to a wide variety of fitness classes 
• An online brain health program, exclusively from AARP® Staying Sharp
• Connecting with others at local health and wellness events, and through the Fitbit® Community for Renew Active

Health Navigators

for Medicare Advantage Members

Health Navigators work with individuals to assist in guiding them through the complexities of the healthcare system due to a complex health event such as diabetes, congestive heart failure, or multiple chronic conditions.  Health Navigators work with individuals to assist in coordinating care with multiple providers and/or facilities and find additional clinical and community programs which may be available.

HouseCalls 

for Medicare Advantage

Members

With the UnitedHealthcare^® HouseCalls program, you get an annual in-home preventive care visit from one of our health care practitioners at no extra cost.

 What does HouseCalls include?

• One 45 to 60-minute at-home visit from a health care practitioner, each year.
• A head-to-toe exam, health screenings and plenty of time to talk about your health questions.
• A custom care plan made just for you.
• Help connecting you with additional care you may need.

Meal Delivery Program 

for Medicare Advantage 

Members

As a member, you can receive up to 84 home delivered meals immediately following an inpatient hospitalization when referred by your UnitedHealthcare^® case manager.

• Meals are delivered to your door in a climate-controlled cooler in  "Fresh-Lock” packaging in shipments of 14 meals or greater
• Meals can be refrigerated for up to 14 days or frozen for up to three months
• Meals are available to support 9 different health conditions
• Meals are provided through our national provider Mom’s Meals^®

Real Appeal for 

Medicare Advantage Members

Real Appeal is a weight loss program that can help members feel and look better. The program provides everything they need to lose weight and keep it off. This program is a pilot for select members residing in Wisconsin.

The online program includes:

• Personalized diabetes prevention coaching
• 24/7 online support and mobile app
• Customizable food, activity, weight and goal trackers
• Success group support, which lets members chat with others who are doing the Real Appeal program
• The weekly Real Appeal All-Star Show featuring healthy tips from celebrities, athletes and health experts

 Success Kit includes:

• Program, nutrition, and fitness guides
• Tools to help cook healthier, tasty meals
• Delivered right to their front door after attending their first group coaching session

Quit For Life

for Medicare Advantage

Members

Quit For Life has helped 3.5 million members quit smoking or using tobacco. It provides the tools and one-on-one support to help you quit your way.

And for UnitedHealthcare members, it’s offered at $0 out of pocket.

 With a 95% satisfaction rate, Quit for Life provides

• Tools and support to help members quit cigarettes, e-cigarettes, vaping and tobacco
• A personal, one-on-one Quit Coach to help you create a customized quit plan
• The Quit for Life mobile app, which offers 24/7 urge management support
• Text2Quit text messages for daily tips and encouragement
• Quit medications – Such as nicotine gum or patches – for no charge, based on eligibility.

Medical and hospital benefits

In most cases, providers and facilities file claims for you.  Provider 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 1-877-835-9861.

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

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

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

Submit your claims to:  UnitedHealthcare, P.O. Box 30555, Salt Lake City, UT 84130-0555.

Prescription drugs

Submit your claims to: OptumRX, PO Box 29044, Hot Springs, AR 71903.

International Claims

In the event that emergency services were required while traveling, submit international claims to: UnitedHealthcare, PO Box 30555, Salt Lake City, UT 84130-0555.

Deadline for filing your claim

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.

Post-service claims procedures 

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

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

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

Authorized Representative

 You may designate an authorized representative to act on your behalf for filing a claim or to appeal claims decisions to us. For urgent care claims, a health care 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.

Notice Requirements

If you live in a county where at least 10 percent of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that non-English language.  You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as 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 health care provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis and procedure codes.

1

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: UnitedHealthcare Federal Employees Health Benefits (FEHB) Program Appeals,

P.O. Box 30573, Salt Lake City, UT 84130-0573 ; 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)  Your email address, if you would like to receive our decision via email.  Please note that by providing your email address, you may receive our decision more quickly.

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

2

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

a) Pay the claim or  

b) Write to you and maintain our denial or.

c) Ask you or your provider for more information

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

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

3

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

You must write to OPM within:

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

Write to OPM at: United States Office of Personnel Management, Federal Employee 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 health care professional with knowledge of your medical condition may act as your authorized representative without your express consent.

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

4

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

If you do not agree with OPM’s decision, your only recourse is to 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.

Note: If you have a serious or life-threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call us at 877-835-9861.  We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal.  You may call OPM’s FEHB 3 at 202 606-0755 between 8 a.m. and 5 p.m. Eastern Time.

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

When you have other health coverage

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

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

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

When we are the secondary payor, we will determine our allowance.  After the primary plan pays, we will pay what is left of our allowance, up to our regular benefit.  We will not pay more than our allowance.  

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

Workers’ Compensation

We do not cover services that:

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

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

Medicaid

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

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

When other Government agencies are responsible for your care

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

When others are responsible for injuries

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

When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) coverage 

Some FEHB plans already cover some dental and vision services. When you are covered by more than one dental/vision plan, coverage provided under your FEHB Plan remains as your primary coverage. FEDVIP coverage pays secondary to that coverage. When you enroll in a dental and/or vision plan on BENEFEDS.com or by phone at 1-877-888-3337, (TTY 1-877-889-5680), you will be asked to provide information on your FEHB plan so that your plans can coordinate benefits. Providing your FEHB information may reduce your out-of-pocket cost.

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

If you are a participant in a clinical trial, and the related care is not covered within the clinical trial, this plan will provide coverage for related costs based on the criteria listed below.

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

• The Original Medicare Plan (Part A or Part B)

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

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

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

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

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

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. You will not need to do anything. To find out if you need to do something to file your claim, call us at 1-877-835-9861 or see our website at: www.myuhc.com. 

 We do not waive any costs if the Original Medicare Plan is your primary payor. 

 .

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

Medicare

Benefit Description - Deductible

High Option You Pay without Medicare: $2,000 Self Only, $4,000 Self Plus One or $4,000 Self and Family

High Option You Pay with Medicare Part B: $2,000 Self Only, $4,000 Self Plus One or $4,000 Self and Family

Benefit Description - Out of Pocket Maximum

High Option You Pay without Medicare: $7,350  Self Only, $14,700 Self Plus One or $14,700 Self and Family

High Option You Pay with Medicare Part B: $7,350  Self Only, $14,700 Self Plus One or $14,700 Self and Family

Benefit Description - Part B Premium Reimbursement

High Option You Pay without Medicare: N/A

High Option You Pay with Medicare Part B: N/A

Benefit Description - Primary Care Physician

High Option You Pay without Medicare: 30% coinsurance

High Option You Pay with Medicare Part B: 30% coinsurance

Benefit Description - Specialist

High Option You Pay without Medicare: 30% coinsurance

High Option You Pay with Medicare Part B: 30% coinsurance

Benefit Description - Inpatient Hospital

High Option You Pay without Medicare: 30% coinsurance

High Option You Pay with Medicare Part B: 30% coinsurance

Benefit Description - Outpatient

High Option You Pay without Medicare: 30% coinsurance

High Option You Pay with Medicare Part B: 30% coinsurance

Benefit Description - Incentives Offerred

High Option You Pay without Medicare: N/A

High Option You Pay with Medicare Part B: N/A

•  Tell us about your Medicare Coverage

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

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

• Medicare Advantage (Part C)

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan.  These are private health care choices (like HMOs and regional PPOs) in some areas of the country. 

To learn more about Medicare Advantage plans, contact Medicare at 1-800-MEDICARE (1-800-633-4227), (TTY 1-877-486-2048) or at www.medicare.gov.

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

This Plan and our Medicare Advantage plan: 

You may enroll in our UnitedHealthcare Medicare Advantage Value Plan and also remain enrolled in our FEHB plan. YOU MUST BE ENROLLED IN THIS FEHB PLAN participating in this program to be eligible for the UnitedHealthcare Medicare Advantage Value Plan - For more information on our Medicare Advantage Value plan, please contact us at 1-844-481-8821. 

You may enroll in the UnitedHealthcare Medicare Advantage Value Plan if:

• You are enrolled in this UnitedHealthcare FEHBP active plan and have both Medicare Part A and Part B
• You are retired and live in our geographic service area. See page (Applies to printed brochure only) for a description of our service area.
• You are a United States citizen or are lawfully present in the United States
• You do NOT have End-Stage Renal Disease (ESRD), with limited exceptions
• You complete an application for enrollment in the UnitedHealthcare Medicare Advantage Value Plan. 

Reimbursement of $50 per month toward your Part B premium will begin on the first of the month following approval of your application. As part of this process CMS will verify your Medicare Part B enrollment. During a calendar year, you may enroll in this Medicare Advantage Value Plan only once. If the FEHB subscriber and/or dependent enrolls in the Medicare Advantage Value Plan, each qualified family member will have to complete an application by calling into our Retiree Services team at(1-844-481-8821).

Members who are not eligible for Medicare Part A and B will remain on the FEHB active plan. If, for any reason, you do not meet the enrollment requirements, you will no longer be eligible to participate in the Medicare Advantage Value plan. Your contributions will end and your regular FEHB benefits will resume. You may be required to repay any reimbursements paid to you in error. 

This plan is designed:

• To help members with their Medicare Part B premium costs
• To provide access to our national network of providers, (in-network or out-of-network) at the same cost share
• To cover eligible medical benefits with little to no out of pocket costs
• To provide coverage with a catastrophic benefit for prescriptions
• Note: You MUST remain enrolled in this FEHB plan to enroll in this Retiree Advantage plan. Do not suspend or terminate this FEHB plan or your Medicare Retiree Advantage plan will also terminate and you will be left without coverage

 The UnitedHealthcare Medicare Advantage Value Plan provides a monthly reimbursement of $50 of your Medicare Part B monthly premium. CMS will process reimbursement directly to your Social Security each month you are covered in the UHCA plan. In addition, we cover benefits, including office visit copayments at ($0), urgent care and emergency care at ($0), plus additional coverage for hearing aids discounts and wellness programs. Note: If you do not receive a social security check please notify us immediately to assist us in making arrangements to reimburse you directly.  

Please see the following chart for your benefits under our Medicare Advantage Value plan.

Benefit Description - Deductible

Member Cost without Medicare: $,2000 Self Only/$4,000 Self Plus One and Self and Family

Member Cost with Medicare Part B: $2,000 Self Only/$4,000 Self Plus One and Self and Family

Member Cost with UnitedHealthcare Medicare Advantage Value Plan: No plan deductible

 Benefit Description - Out-of-Pocket Maximum

Member Cost without Medicare: $7,350 Self Only $14,700 Self Plus One and $14,700 Self and Family

Member Cost with Medicare Part B: $7,350 Self Only $14,700 Self Plus One and $14,700 Self and Family

Member Cost with UnitedHealthcare Medicare Advantage Value Plan: You pay nothing for Medicare-covered service from any provider

Benefit Description - Primary Care Physician

Member Cost without Medicare: 30% coinsurance

Member Cost with Medicare Part B: 30% coinsurance

Member Cost with UnitedHealthcare Medicare Advantage Value Plan: $0

Benefit Description - Specialists

Member Cost without Medicare: 30% coinsurance

Member Cost with Medicare Part B: 30% coinsurance

Member Cost with UnitedHealthcare Medicare Advantage Value Plan: $0

Benefit Description - Virtual Visits

Member Cost without Medicare: 30% coinsurance

Member Cost with Medicare Part B: 30% coinsurance

Member Cost with UnitedHealthcare Medicare Advantage Value Plan: $0

Benefit Description - Urgent Care

Member Cost without Medicare: 30% coinsurance

Member Cost with Medicare Part B:30% coinsurance 

Member Cost with UnitedHealthcare Medicare Advantage Value Plan: $0

Benefit Description - Emergency

Member Cost without Medicare: 30% coinsurance

Member Cost with Medicare Part B: 30% coinsurance

Member Cost with UnitedHealthcare Medicare Advantage Value Plan: $0

Benefit Description - Inpatient Hospital

Member Cost without Medicare: 30% coinsurance

Member Cost with Medicare Part B: 30% coinsurance

Member Cost with UnitedHealthcare Medicare Advantage Value Plan: $0

Benefit Description - Outpatient Hospital

Member Cost without Medicare: 30% coinsurance

Member Cost with Medicare Part B: 30% coinsurance

Member Cost with UnitedHealthcare Medicare Advantage Value Plan: $0

Benefit Description - RX Retail 30-day Supply

Member Cost without Medicare: Tier 1-$15, Tier 2-$45, Tier 3-$85,Tier 4-$200

Member Cost with Medicare Part B: Tier 1-$15, Tier 2-$45, Tier 3-$85,Tier 4-$200

Member Cost with UnitedHealthcare Medicare Advantage Value Plan: Tier 1-$7, Tier 2-$35, Tier 3-$65, Tier 4–$100

Benefit Description - RX Mail Order 90-daty Supply

Member Cost without Medicare: Tier 1-$45, Tier 2-$135, Tier 3-$255, Tier 4-$600

Member Cost with Medicare Part B: Medicare: Tier 1-$45, Tier 2-$135, Tier 3-$255, Tier 4-$600

Member Cost with UnitedHealthcare Medicare Advantage Value Plan: Tier 1-$14, Tier 2-$70, Tier 3-$130, Tier 4-$200

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) but we will not waive any of our copayments or coinsurance. If you enroll in a Medicare Advantage 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 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.) If you enroll in our Medicare Advantage Value plan above, do NOT suspend your FEHB plan as it is required to remain in place to enroll in our Medicare Advantage value plan. If you were to suspend or terminate your FEHB plan the Medicare Advantage plan will also terminate.   For information on suspending your FEHB enrollment, contact your retirement office.  If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage or move out of the Medicare Advantage plan’s service area.

• Medicare prescription drug coverage (Part D)

Clinical Trials Cost Categories

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

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

Coinsurance

See Section 4, page (Applies to printed brochure only).

Copayment

See Section 4, page (Applies to printed brochure only),

Cost-Sharing

See Section 4, page (Applies to printed brochure only).

Custodial care

Services that are non-health related, such as daily living activities, or services which are health related but do not seek to cure, or services which do not require a trained medical professional. Custodial care that lasts 90 days or more is sometimes known as long term care.

Deductible

See Section 4, page (Applies to printed brochure only).

Experimental or investigational service

 Experimental or Investigational Service(s) - medical, surgical, diagnostic, psychiatric, mental health, substance use disorders or other health care services, technologies, supplies, treatments, procedures, drug therapies, medications or devices that, at the time we make a determination regarding coverage in a particular case are determined to be any of the following:

• Not approved by the S. Food and Drug Administration (FDA) to be lawfully marketed for the proposed use and not identified in the American Hospital Formulary Service or the United States American Hospital Pharmacopoeia Dispensing Information as appropriate for the proposed use
• Not recognized, in accordance with generally accepted medical standards, as being safe and effective for your condition;
• Subject to review and approval by any institution review board for the proposed use. (Devices which are FDA approved under the Humanitarian Use Device exemption are not considered to be

Experimental or Investigational).

The subject of an ongoing clinical trial that meets the definition of a Phase 1, 2 or 3 clinical trial set forth in the FDA regulations, regardless of whether the trial is actually subject to FDA oversight

Medical necessity

Health care services provided for the purpose of preventing, evaluating, diagnosing or treating a sickness, injury, mental illness, substance use disorder disease or its symptoms, that are all of the following as determined by us or our designee, within our discretion.

• In accordance with Generally Accepted Standards of Medical Practice.
  Clinically appropriate, in terms of type, frequency, extent, site and duration, and considered effective for your sickness, injury, mental illness, substance use disorder, disease or its symptoms. 
• Not mainly for your convenience or that of your doctor or other health care provider 
• Not more costly than an alternate drug, service(s) or supply that is at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of your sickness, injury, disease or symptoms.

Generally Accepted Standards of Medical Practice are standards that are based on credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, relying primarily on controlled clinical trials, or if not available, observational studies from more than one institution that suggest a causal relationship between the service or treatment and health outcomes. The fact that a Physician may prescribe, authorize or direct a service does not of itself make it Medically Necessary or covered by this Plan.

If no credible scientific evidence is available then standards are based on Physician specialty society recommendations or professional standards of care may be considered. We reserve the right to consult expert opinion in determining whether health care services are Medically Necessary.

Plan Allowance

Allowable Expense (plan allowance) is a health care expense, including deductibles, coinsurance and copayments, that is covered at least in part by any Plan covering the person. When a Plan provides benefits in the form of services, the reasonable cash value of each service will be considered an Allowable Expense and a benefit paid. An expense that is not covered by any Plan covering the person is not an Allowable Expense. In addition, any expense that a provider by law or in accordance with a contractual agreement is prohibited from charging a covered person is not an Allowable Expense.

Reimbursement

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

Unproven services

Unproven services, including medications, that are determined not to be effective for treatment of the medical condition and/or not to have a beneficial effect on health outcomes due to insufficient and inadequate clinical evidence from well-conducted randomized controlled trials or cohort studies in the prevailing published peer-reviewed medical literature.

• 
  Well-conducted randomized controlled trials. (Two or more treatments are compared to each other, and the patient is not allowed to choose which treatment is received.) 
•  Well-conducted cohort studies from more than one institution. (Patients who receive study treatment are compared to a group of patients who receive standard therapy. The comparison group must be nearly identical to the study treatment group).

We have a process by which we compile and review clinical evidence with respect to certain health services. From time to time, we issue medical and drug policies that describe the clinical evidence available with respect to specific health care services. These medical and drug policies are subject to change without prior notice. You can view these policies at www.myuhc.com.

Please note: If you have a life-threatening Sickness or condition (one that is likely to cause death within one year of the request for treatment ) we may, in our discretion consider an otherwise Unproven Service to be a Covered Health Service for that Sickness or condition. Prior to such a consideration, we must first establish that there is sufficient evidence to conclude that, albeit unproven, the service has significant potential as an effective treatment for that Sickness or condition.

Urgent care claims

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

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

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

If you believe your claim qualifies as an urgent care claim, please contact our Customer Service Department at 877-835-9861.  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.

Us/We

Us and We refer to 

 Medical services provided by physicians: Diagnostic and treatment services provided in the office *

Office visit copay: Primary Care Physician (PCP) - 30% coinsurance

Specialist - 30% coinsurance

(Applies to printed brochure only)

Services provided by a hospital: Inpatient *

30% coinsurance

(Applies to printed brochure only)

Services provided by a hospital: Outpatient*

30% coinsurance

(Applies to printed brochure only)

Emergency benefits: In or out-of-area* 

 30% coinsurance

(Applies to printed brochure only)

Mental health and substance use disorder treatment*:

Regular cost-sharing

(Applies to printed brochure only)

Prescription drugs:  Retail pharmacy* (30-day supply)

Tier 1: $15; Tier 2: $45; Tier 3: $85; Tier 4: $200

(Applies to printed brochure only)

Prescription drugs:  Mail order* (90-day supply)

Tier 1:$45; Tier 2: $135; Tier 3: $255; Tier 4: $600

(Applies to printed brochure only)

Accidental Dental and Adjunct Dental Care*:

30% coinsurance

(Applies to printed brochure only)

Vision care - for eye refraction examination 

30% coinsurance

(Applies to printed brochure only)

Special features: 

 UnitedHealthcare® app, Quit for Life®, Maternity Support Program, Spine and Joint Program, UnitedHealth Premium, Real Appeal, Specialty Pharmacy, Flexible Benefits Option, Cancer Clinical Trials

(Applies to printed brochure only)

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

Nothing after $7,350 Self Only; $14,700 Self plus One or $14,700 Self and Family

Some costs do not count toward this protection

(Applies to printed brochure only)

Non-FEHB Benefits

PPO Preventive dental plan provided at no charge to all members; resources for hearing aids and other financial options available for our members

(Applies to printed brochure only)