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

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

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

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

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

We do not determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office.  For information on your premium deductions, 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 carrier to add a family member when there is already family Coverage.

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

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits, nor will we. Please tell us immediately of 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 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 2023 benefits of your prior plan or option.  If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2022 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

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

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 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 60^th day after the end of the 31 day temporary extension.

You may be eligible for spouse equity coverage or assistance or Temporary Continuation of Coverage (TCC) or a conversion policy (a non-FEHB individual policy).

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

If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal or Tribal job, or if you are a covered 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 866-895-5828 or visit our website at www.iuhealthplans.org.

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 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 866-895-5828 or write to us at 950 N Meridian St, Suite 400 Indianapolis, IN 46204.  You may also request replacement cards through our website: www.iuhealthplans.org.

You get covered care from “Plan providers” and “Plan facilities.” You will only pay copayments, deductibles, and/or coinsurance, if you use our Open Access program you can receive covered services from a participating network specialist without a required referral from your primary care physician or by another participating provider in the network.

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

We list Plan providers in the provider directory, which we update periodically.  The list is also on our website.  The provider directory for this plan can be found at www.iuhealthplans.org. Providers can be located by selecting the "Employer Plan - IU Health Select Network" product option. 

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 866-895-5828 for assistance.

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

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. 

Your primary care physician can be a general practitioner, family practitioner, internist or pediatrician. Your primary care physician will provide or coordinate most of your health care.

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

Your primary care physician may refer you to a specialist for needed care or you may go directly to a specialist without a referral. However, some services require prior authorization. A prior authorization list can be found at www.iuhealthplans.org.

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

• If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. 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. 
• 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 out service area and you enroll in another FEHB plan;

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

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

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

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our Member Services department immediately at 866-895-5828. If you are new to the FEHB Program, we will arrange for you to receive care and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

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

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

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

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

You must get prior approval for certain services. Failure to do so will result in services not being covered.

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

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

For a complete list of services that require a prior authorization refer to: www.iuhealthplans.org. 

Your provider can fax completed prior authorization forms to Population Health Medical Management at 317-962-6219 or call 317-962-2378 if your provider have questions about prior authorization and referrals. Medical Management is open Monday through Friday, 8:30 a.m. - 4:30 p.m. For urgent requests on weekends/holidays call 317-962-2378. 

First, your physician or hospital must call us at 317-962-2378 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 verbally 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 (1) of 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 866-895-5828. 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 866-895-5828. 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 48 hours following the day of the emergency admission or as soon as possible within a reasonable period of time even if you have been discharged from the hospital. 

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

Note: When a newborn requires definitive treatment during or after the mother’s confinement, the newborn is considered a patient in 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.

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 844-432-0704.

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. 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.

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.

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

Example: When you see your primary care physician, you pay a copayment of $25 per office visit or a copayment of $35 per office visit when you see a participating specialist.

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.

Example: With IU Health Plans Select, you will need to meet the deductible of $250 for Self Only enrollment or $500 for Self Plus One or Self and Family enrollment.

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.

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 10% of our allowance for durable medical equipment.

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 coinsurance) total $6,000 for Self Only enrollment or $12,000 for Self Plus One enrollment or Self and Family enrollment for the High Option in any calendar year, you do not have to pay any more for covered services.  Once an individual meets the Self Only out-of-pocket maximum under the Self Plus One or Self and Family enrollment, the Plan will begin to cover eligible medical expenses at 100%. The remaining balance of the Self Plus One and Self and Family out-of-pocket maximum can be satisfied by one or more family members. 

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

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

Facilities of the Department of Veterans Affairs, the Department of Defense and the Indian Health Services are entitled to seek reimbursement from us for certain services and supplies they provide to you or a family member. They may not seek more than their governing laws allow.  You may be responsible to pay for certain services and charges.  Contact the government facility directly for more information.

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

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

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

In addition, State of Indiana does not have an independent law and abides by NSA federal law and the requirements described under Code section 9816, ERISA section 716, and PHS Act section 2799A-1.

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to iuhealthplans.org or contact the health plan at 866-895-5828.

• Healthcare FSA (HCFSA) – Reimburses you for eligible out-of-pocket healthcare expenses (such as copayments, deductibles, physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you, your tax dependents, and your adult children (through the end of the calendar year in which they turn 26).

• FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans.  This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.

Professional services of physicians

• In physician’s office

$25 per primary care physician (PCP) visit

$35 per specialist visit

• During a hospital stay

$250 Copayment. Waived if admitted.

• Inpatient Skilled Nursing Facility Services (limited to a maximum of 90 days per Enrollee Per Year)

10% Coinsurance after Deductible

• In an urgent care center

$30 per visit

• At home

10% Coinsurance after deductible

• Telehealth Services

$20 Copayment per visit

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine Pap tests
• Pathology
• X-rays
• Non-routine mammograms
• Ultrasound
• Electrocardiogram and electroencephalogram (EEG)
• Sleep Studies

10% Coinsurance after deductible

Diagnostic tests limited to:

• X-ray and other radiology services, including mammograms for any person diagnosed with breast disease.
• Magnetic Resonance Angiography (MRA).
• Magnetic Resonance Imaging (MRI).
• CAT scans.
• Laboratory and pathology services.
• Cardiographic, encephalographic, and radioisotope tests.
• Nuclear cardiology imaging studies.
• Ultrasound services.
• Allergy tests.
• Electrocardiograms (EKG).
• Electromyograms (EMG) except that surface EMGs are not Covered Services.
• Echocardiograms.
• Bone density studies
• Positron emission tomography (PET scanning).
• Diagnostic Tests as an evaluation to determine the need for a Covered Transplant Procedure.
• Echographies
• Doppler studies.
• Brainstem evoked potentials (BAER)
• Somatosensory evoked potentials (SSEP)
• Visual evoked potentials (VEP).
• Nerve conduction studies.
• Muscle testing.
• Electrocorticograms.

Note: The services need precertification. See Section 3 "Services requiring our prior approval".

*Note: Benefits are available for specialized diagnostic genetic testing when it is medically necessary to diagnose and/or manage a patient's medical condition.

10% Coinsurance after Deductible

• Genetic Counseling and Evaluation for BRCA Testing
• Genetic Testing for BRCA-Related Cancer*

*Note: Requires precertification. See Section 3 "Services requiring our prior approval".

• Routine physicals - one (1) exam every calendar year

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

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

Routine mammogram - covered

• One (1) every calendar year; or when medically necessary

Nothing

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

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

Not covered:

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

• Well-child visits, examinations, and immunizations other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org
• Immunizations such as DTaP, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/index.html

• You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://www.uspreventiveservicestaskforce.org
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder

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

Not covered:

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

All charges

Complete maternity (obstetrical) care, such as:

• Prenatal Care
• Screening for gestational diabetes
• Delivery
• Postnatal care

No copay for routine prenatal care or postpartum care visit

10% Coinsurance after Deductible

Breastfeeding support, supplies and counseling for each birth.

Note: Here are some things to keep in mind:

You do not need to precertify your vaginal delivery; see page 18 for other circumstances, such as extended stays for you or your baby.

• 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   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.  Surgical benefits, not maternity benefits, apply to circumcision.
• 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 confinement, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

.

Not covered: If Maternity services are not covered for any reason, Hospital charges for ordinary routine nursery care for a well newborn are also not covered.

All charges

Contraceptive counseling on an annual basis

Nothing

A range of voluntary family planning services, limited to:

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

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

Nothing

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

10% Coinsurance after Deductible

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic testing and counseling

Infertility is a disease defined by the failure to conceive a pregnancy after 12 months or more of timed intercourse or egg-sperm contact for women under age 35 (6 months for women age 35 or older).

Diagnosis and treatment of infertility, such as:

• Testing for diagnosis and surgical treatment of the underlying medical cause of infertility.
• Fertility preservation procedures (retrieval of and freezing of eggs or sperm) for members facing the possibility of infertility caused by chemotherapy, pelvic radiotherapy, other gonadotoxic therapies, or ovary or testicle removal for treatment of disease.* **
• Any assisted reproductive technology (ART) procedure or services related to such procedures, including but not limited to in-vitro fertilization (IVF), gamete intra-fallopian transfer (GIFT), zygote intra-fallopian transfer (ZIFT), and intra-cytoplasmic sperm injection (ICSI) or
  • Artificial insemination (AI) and monitoring of ovulation:
    • Intravaginal insemination (IVI)
    • Intracervical insemination (ICI)
    • Intrauterine insemination (IUI)
  • Ovulation induction cycle(s) while on injectable medication to stimulate the ovaries
  • Any charges associated with care required to obtain artificial insemination or ART services (e.g. office, hospital, ultrasounds, laboratory tests, etc); and any charges associated with obtaining sperm for any artificial insemination or ART procedures except as stated above
  • The purchase of donor sperm when necessary for conception; the purchase of donor eggs when necessary for conception; and, any charges associated with care of the donor required for donor egg retrievals or transfers
  • Injectable fertility drugs including but not limited to menotropins, hCG, GnRH agonists, and IVIG.
  • Services provided in the setting of ovulation induction such as ultrasounds, laboratory studies, and physician services.
  • Services and supplies related to the above mentioned services, including sperm processing
  • Infertility treatments such as in vitro fertilization that might be needed after the necessary medical intervention

Note:  We cover Injectable fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit.

* Subject to medical necessity

** Note: Requires Precertification. See Section 3 “Services requiring our prior approval”. You are responsible for ensuring that we are asked to precertify your care; you should always ask your physician or hospital whether they have contacted us.

10% Coinsurance after Deductible, up to a combined annual limit of $20,000 for medical and prescription drugs. 

Not covered:

• All charges associated with a gestational carrier program for the covered person or gestational carrier
• Reversal of sterilization surgery
• Treatment for infertility when the cause of the infertility was a previous sterilization with or without surgical reversal
• Elective fertility preservation, such as egg freezing sought due to natural aging
• Cost of home ovulation predictor kits or home pregnancy kits
• Drugs related to the treatment of non-covered benefits
• Storage costs

• Testing and treatment
• Allergy injections

10% Coinsurance after Deductible

• 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 in Section 5(b).

• Respiratory and inhalation therapy
• Dialysis – hemodialysis and peritoneal dialysis
• Intravenous (IV) Infusion Therapy in a doctor’s office or facility (For IV infusion and antibiotic treatment at home, see Home Health Services.)
• Growth hormone therapy (GHT)

Note: Treatment therapies may require prior authorization. Please call 317-962-2378 or 866-492-5878 to determine medical necessity and prior authorization.

Note: Growth hormone therapy is covered under the prescription drug benefit. We will only cover GHT when we preauthorize the treatment. Call 317-962-2378 or 866-492-5878 for preauthorization. We will ask you to submit information that establishes that the GHT is medically necessary. Ask us to authorize GHT before you begin treatment; otherwise, we will only cover GHT services from the date you submit the information and it is authorized by IU Health Plans. If you do not ask or if we determine GHT is not medically necessary, we will not cover the GHT or related services and supplies. See Services requiring our prior approval in Section 3.

10% Coinsurance after Deductible

Non-Preventive Medical Nutritional Therapy

Nothing

Not covered: 

• Food additives are not covered in all cases.
• Grocery items and over-the-counter items are non-covered in all cases.
• Nutritional supplements must be considered a Medical Food in order to be covered.
• Medical Food Not Medically Necessary and not covered.

All charges

20 visits per person, per calendar year for physical or occupational therapy for the services of each of the following:

• Qualified Physical therapists
• Occupational therapists

Note: We only cover therapy when a physician:

• Orders the care;
• Identifies the specific professional skills the patient requires and the medical necessity for skilled services; and
• Indicates the length of time the services are needed.

10% Coinsurance after Deductible

Not covered:

• Repetitive exercise to improve movement, maintain strength and increase endurance (including assistance with walking for weak or unstable patients).
• Range of motion and passive exercises that are not related to restoration of a specific loss of function but are for maintaining a range of motion in paralyzed extremities
• General exercise programs, diathermy, ultrasound, and heat treatments for pulmonary conditions 
• Diapulse
• Work hardening
• Maintenance therapy to delay or minimize muscular deterioration in patients suffering from chronic disease or illness

• 20 visits per member per calendar year of pulmonary rehabilitation to treat functional pulmonary disability
• 36 visits per member per calendar year of Cardiac rehabilitation

10% Coinsurance after Deductible

Not Covered: Long-term rehabilitative therapy

• 20 visits per person per calendar year

10% Coinsurance after Deductible.  

• 20 visits per person, per calendar year

10% Coinsurance after Deductible

• 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.

10% Coinsurance after Deductible

Not covered:

• Hearing aids or examinations to prescribe or fit the hearing aids
• All other hearing testing not medically necessary
• Hearing services that are not shown as covered

• Treatment of eye diseases and injury

10% Coinsurance after Deductible

Pediatric Vision Services - covered services only for enrollee until the last day of the month in which they obtain the age of 19. 

• Pediatric eye exam
• eyeglass lenses
• frames
• contact lenses
• low vision benefits

10% Coinsurance after Deductible

Not covered: Adult vision services

• Orthoptic or vision training, subnormal vision aids and any associated supplemental testing; Aniseikonic lenses
• Medical and/or surgical treatment of the eye, eyes or supporting structures
• An eye or vision examination, or any corrective eyewear required by your Employer as a condition of employment, safety eyewear
• Plan (non-prescription) lenses and/or contact lenses
• Non-prescription sunglasses
• Two pair of glasses in lieu of bifocals
• Fitting of contact lenses
• Vision therapy, including eye patches and eye exercises, e.g., orthoptics, pleoptics, for the treatment of conditions related to learning disabilities or developmental delays
• Radial keratotomy and laser eye surgery, including related procedures designed to surgically correct refractive errors

10% Coinsurance after Deductible

Not covered:

• Routine foot care (including the cutting or removal of corns and calluses), nail trimming, cutting, or debriding, hygienic and preventive maintenance foot care, including but not limited to cleaning and soaking the feet, applying skin creams in order to maintain skin tone, and other services that are performed when there is not a localized illness, injury or symptom involving the foot
• Surgical treatment of flat feet; subluxation of the foot; weak, strained, unstable feet; tarsalgia; metatarsalgia; hyperkeratoses
• Foot orthotics
• Podiatric shoe inserts

• Orthopedic devices such as braces and prosthetic devices such as artificial limbs and eyes.
• Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy.
• Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, bone anchored hearing aids (BAHA), penile implants, defibrillator, surgically implanted breast implant following mastectomy, and lenses following cataract removal.
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.
• cochlear implant
• Ostomy supplies specific to ostomy care (quantities and types vary according to ostomy, location, construction, etc.)

Note: Certain devices require precertification by you or your physician. Please see Section 3 for a list of services that require precertification.

10% Coinsurance after Deductible

• Hair prosthesis prescribed by a physician for hair loss resulting from radiation therapy, chemotherapy or certain other injuries, diseases, or treatment of a disease.

10% Coinsurance after Deductible.  Coverage includes the first one following cancer treatment resulting in hair loss, not to exceed one per calendar year.

Not covered:

• Dentures, replacing teeth or structures directly supporting teeth unless related to an accident or approved facial reconstruction
• Dental appliances
• Such non-rigid appliances as elastic stockings, garter belts, arch supports, and corsets
• Artificial heart implants
• Wigs (except as described above following cancer treatment)
• Penile prosthesis in men suffering impotency resulting from disease or injury
• Hearing aids, testing, fitting and the examination for them
• Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups 
• Standard elastic stockings, garter belts, and other supplies not specially made and fitted (except as specified under Medical Supplies

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment. Contact the plan for a complete list of covered DME. Some covered items include:

• Oxygen
• Dialysis equipment
• Hospital beds (Clinitron and electric beds must be preauthorized)
• Wheelchairs (motorized wheelchairs and scooters must be preauthorized)
• Crutches
• Walkers
• Insulin pumps and related supplies such as needles and catheters
• Nutritional formulas for the treatment of inherited metabolic diseases, including histidinemia, homocystinuria, maple syrup urine disease, phenylketonuria, and tyrosinemia, as well as specialized infant formulas (e.g., Alimentum, Elecare, Neocate, and Nutramigen) in the presence of such conditions as severe food protein allergies, when administered under the direction of a Plan doctor.

Note: You must get your DME from a participating DME provider. Some DME may require precertification by you or your physician.

10% Coinsurance after Deductible

Not covered:

• Elastic stockings and support hose
• Bathroom equipment such as bathtub seats, benches, rails and lifts
• Home modifications such as stair glides, elevators and wheelchair ramps
• Wheelchair lifts and accessories needed to adapt to the outside environment or convenience for work or to perform leisure or recreational activities

• Home health services ordered by a Plan Physician and provided by nurses and home health aides through a participating home health care agency. Home health services include skilled nursing services provided by a licensed nursing professional; services provided by a physical therapist, occupational therapist, or speech therapist; and services of a home health aide when provided in support of the skilled home health services. Home health services are limited to a maximum of 100 visits per enrolee per year.
• Private Nursing Visits are limited to a maximum of 82 visits per enrollee per year and 164 visits per enrollee per lifetime

10% Coinsurance after Deductible

Not covered:

• Food, that is not a formula that is intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and formulated to be consumed or administered enterally under the direction of a physician
• housing, homemaker services and home delivered meals. 
• Physician charges except for Telehealth and Hospital at Home 
• Home hemodialysis services
• Helpful environmental materials (handrails, ramps, telephones, air conditioners, and similar services, appliances, and devices). 
• Services provided by registered nurses and other health workers who are not acting as employees or under approved arrangements with a contracting Home Health Care Provider
• Services provided by volunteer ambulance associations for which patient is not obligated to pay.
• Visiting teachers, vocational guidance, and other counselor 
• Services related to outside, occupational, and social activities

Chiropractic services up to 12 visits per member per calendar year

• Manipulation of the spine and extremities
• Adjunctive procedures such as ultrasound, electric muscle stimulation, vibratory therapy and cold pack application

10% Coinsurance after Deductible

Not covered:

• Any services not listed above
• Manipulation Therapy services rendered in the home as part of Home Care Services are not covered

Acupuncture 

Not covered

Not covered:  Other alternative medical treatments including but not limited to:

• Acupuncture other than stated above
• Holistic medicine
• Homeopathy
• Hypnosis
• Aroma therapy
• massage and massage therapy
• reiki therapy
• herbal
• vitamin or dietary products or therapies
• naturopathy
• thermography
• orthomolecular therapy
• contact reflex analysis
• bioenergy synchronization technique

Indiana University Health, Inc. offers disease management for multiple conditions. Included are programs for:

• Asthma
• Cerebrovascular disease
• Chronic obstructive pulmonary disease (COPD)
• Congestive heart failure (CHF)
• Coronary artery disease
• Cystic Fibrosis
• Depression
• Diabetes
• Adult and Child obesity screening programs and treatment interventions
• Hepatitis
• Inflammatory bowel disease
• Kidney failure
• Low back pain
• Sickle Cell disease

To request more information on our disease management programs, call 866-895-5828.

Coverage is provided for:

• Tobacco cessation Programs including individual/group/phone counseling, and for over-the-counter (OTC) and prescription drugs approved by the FDA to treat nicotine dependence. 

Note:  OTC drugs will not be covered unless you have a prescription and the prescription is presented at the pharmacy and processed through our pharmacy claim system.

Nothing for four (4) smoking cessation counseling sessions per quit attempt and two (2) quit attempts per year.

Nothing for OTC drugs and prescription drugs approved by the FDA to treat nicotine dependence.

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

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

• Voluntary sterilization for men (e.g., vasectomy)
• Treatment of burns
• Skin grafting and tissue implants
• Gender affirming surgery**

** Note: Requires Precertification. See Section 3 “Services requiring our prior approval”. You are responsible for ensuring that we are asked to precertify your care; you should always ask your physician or hospital whether they have contacted us. For precertification or criteria subject to medical necessity, please contact us at 866-492-5878.

10% Coinsurance after Deductible

Not covered:

• Bariatric surgery
• Reversal of voluntary surgically-induced sterilization
• Surgery primarily for cosmetic purposes
• Radial keratotomy and laser surgery, including related procedures designed to surgically correct refractive errors
• Routine treatment of conditions of the foot; (see Foot care)
• Gender reassignment services that are not considered medically necessary

• 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 and developmental anomalies are cleft lip, cleft palate, webbed fingers and webbed toes.  All surgical requests must be preauthorized.
• 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 lymphedema
  • 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 (including, but not limited to)**

- Surgical removal of breasts for female-to-male patients
- Breast augmentation (implants/lipofilling) in male-to-female patients
- Surgical removal of uterus and ovaries in female-to-male and and testes in male-to-female
- Reconstruction of external genitalia**

** Note: Requires Precertification. See Section 3 “Services requiring our prior approval”. You are responsible for ensuring that we are asked to precertify your care; you should always ask your physician or hospital whether they have contacted us. For precertification or criteria subject to medical necessity, please contact us at 866-492-5878.

10% Coinsurance after Deductible

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, that are medical in nature, such as:

• Treatment of fractures of the jaws or facial bones;
• Removal of stones from salivary ducts;
• Excision of benign or malignant lesions;
• Medically necessary surgical treatment of TMJ (must be preauthorized); 
• Excision of tumors and cysts; and 
• Removal of bony impacted wisdom teeth

10% Coinsurance after Deductible

Not covered:

• Dental implants
• Dental care (such as restorations) involved with the treatment of temporomandibular joint (TMJ) pain dysfunction syndrome

These solid organ transplants are covered.  Solid organ transplants are limited to:

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

10% Coinsurance after Deductible

These tandem blood or marrow stem 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 Hodgkin’s lymphoma with recurrence (relapsed)

-   Advanced Myeloproliferative Disorders (MPDs)

-   Advanced neuroblastoma

-   Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)

-   Amyloidosis

-   Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)

-   Hemoglobinopathy

-   Infantile malignant osteopetrosis

-   Kostmann’s syndrome

-   Leukocyte adhesion deficiencies

-   Marrow failure and related disorders (i.e., Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria, Pure Red Cell Aplasia)

-   Mucolipidosis (e.g., Gaucher’s disease, metachromatic leukodystrophy, adrenoleukodystrophy)

-   Mucopolysaccharidosis (e.g., Hunter’s syndrome, Hurler’s syndrome, Sanfillippo’s syndrome, Maroteaux-Lamy syndrome variants)

-   Myelodysplasia/Myelodysplastic syndromes

-   Paroxysmal Nocturnal Hemoglobinuria

-   Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-Aldrich syndrome)

-   Severe combined immunodeficiency

-   Severe or very severe aplastic anemia

-   Sickle cell anemia

-   X-linked lymphoproliferative syndrome

• Autologous 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
  • Breast Cancer
  • Ependymoblastoma
  • Epithelial ovarian cancer
  • Ewing’s sarcoma
  • Multiple myeloma
  • Medulloblastoma
  • Multiple myeloma
  • Pineoblastoma
  • Neuroblastoma
  • Testicular, Mediastinal, Retroperitoneal, and Ovarian germ cell tumors

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

-   Advanced Hodgkin’s lymphoma with recurrence (relapsed)

-   Advanced Myeloproliferative Disorders (MPDs)

-   Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)

-   Amyloidosis

-   Chronic lymphocytic leukemia/small lymphocytic 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
  • Chronic inflammatory demyelination polyneuropathy (CIDP)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Sickle Cell anemia

• Mini-transplants (non-myeloablative 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/Myelodysplastic Syndromes
  • Myeloproliferative disorders (MDDs)
  • Non-small cell lung cancer
  • Ovarian cancer
  • Prostate cancer
  • Renal cell carcinoma
  • Sarcomas
  • Sickle cell anemia

• Autologous Transplants for
  • Advanced childhood kidney cancers
  • Advanced Ewing sarcoma
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Aggressive non-Hodgkin lymphomas
  • 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)
  • Multiple sclerosis
  • Small cell lung cancer
  • Systemic lupus erythematosus
  • Systemic sclerosis

• National Transplant Program (NTP) - Transplants which are non-experimental or non-investigational are a covered benefit. Covered transplants must be ordered by your primary care doctor and plan specialist physician and approved by our medical director in advance of the surgery. The transplant must be performed at hospitals (Institutes of Excellence) specifically approved and designated by us to perform these procedures. A transplant is non-experimental and non-investigational when we have determined, in our sole discretion, that the medical community has generally accepted the procedure as appropriate treatment for your specific condition. Coverage for a transplant where you are the recipient includes coverage for the medical and surgical expenses of a live donor, to the extent these services are not covered by another plan or program.

*Note: Transplants must be performed at hospitals designated as Institutes of Excellence (IOE). Hospitals in our network, but not designated as an IOE hospital will not be covered.

Refer to Note

Refer to Note

Not covered:

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

Professional services provided in:

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

Note: For sedation or anesthesia relating to dental services performed in a dental office, see Section 5(g), Dental benefits.

Note: When the anesthesiologist is the primary giver of services, such as for pain management, the specialist copay applies.

10% Coinsurance after Deductible

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 products, derivatives and components, artificial blood products and biological serum. Blood products include any product created from a component of blood such as, but not limited to, plasma, packed red blood cells, platelets, albumin, Factor VIII, Immunoglobulin, and prolastin
• 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.

$250 Copayment

Not covered:

• Non-covered facilities, such as nursing homes, schools
• Custodial care, rest cures, domiciliary or convalescent cares
• Personal comfort items, such as phone and television
• Private nursing care

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Radiologic procedures, diagnostic laboratory tests, and X-rays when associated with a medical procedure being done the same day
• Pathology Services
• Administration of blood, blood plasma, and other biologicals
• Blood products, derivatives and components, artificial blood products and biological serum
• Pre-surgical testing
• Dressings, casts, and sterile tray services
• Medical supplies, including oxygen
• Anesthetics and anesthesia service 
• Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, bone anchored hearing aids (BAHA), penile implants, defibrillator, surgically implanted breast implant following mastectomy, and lenses following cataract removal. 

Note: Certain devices require precertification by you or your physician. Please see Section 3 for a list of services that require precertification.

Note:  Preventive care services are not subject to copays listed.

$100 Copayment

Not covered: Whole blood and concentrated red blood cells not replaced by the member.

Inpatient Skilled Nursing Facility Services

• limited to a maximum of 90 days per member per year

10% Coinsurance after Deductible

Hospice care may be provided in the home or at a hospice facility where medical, social, and psychological services are given to help treat patients with a terminal illness. Hospice services include routine home care, continuous home care, Inpatient hospice, and Inpatient respite. To be eligible for hospice Benefits, the patient must have a life expectancy of six months or less, as certified by the attending physician and hospice medical director. Covered Services will continue if the Enrollee lives longer than six months, provided the hospice medical director or other hospice physician recertifies that the Enrollee is terminally ill.

10% Coinsurance after Deductible

Not covered: Separately billed services provided by volunteers and housekeeping services

All charges

Ambulance Services are transportation by a vehicle (including ground, water, and Air Ambulance transportation) designed, equipped, and used only to transport the sick and injured and staffed by Emergency Medical Technicians (EMT), paramedics, or other certified medical professionals:

• From your home, scene of an accident or medical Emergency to a Hospital
• Between Hospitals
• Between a Hospital and Skilled Nursing Facility; or
• From a Hospital or Skilled Nursing Facility to your home, if Medically Necessary 
• From a Health Care Facility to a Hospital 
• Between the Enrollee's residence and a Health Care Facility 
• Between a site of transfer and a Hospital

10% Coinsurance after Deductible

Not covered:

• A trip to a morgue or funeral home
• Any Ambulance usage for the convenience of an enrollee, family, or provider
• Ambulance transportation for member convenience or reasons that are not medically necessary

Note:  Elective air ambulance transport, including facility-to-facility transfers, requires prior approval from the Plan.

• Emergency or urgent care at a doctor’s office

$25 per PCP visit

$35 per specialist visit

• Emergency or urgent care at an urgent care center

$30 per visit

• Emergency Outpatient Care at a Hospital

$250 Copayment per visit

Note: If you are admitted from the Emergency Room to a hospital, the copay is waived.

All charges

• Emergency or urgent care at a doctor’s office

$25 per primary care visit

$35 per specialist visit

• Emergency or urgent care at an urgent care center

$30 per visit

• Emergency Outpatient Care at a Hospital

$250 per visit

Note: If you are admitted from the Emergency Room to a hospital, the copay is waived.

Not covered:

• Elective care or non-emergency care and follow-up care recommended by non-Plan providers that has not been approved by the Plan or provided by Plan providers
• Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
• Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area.

IU Health Virtual Visits app- iuhealth.org/virtualvisits

$20 Copayment per visit

Ambulance Services are transportation by a vehicle (including ground, water, and Air Ambulance transportation) designed, equipped, and used only to transport the sick and injured and staffed by Emergency Medical Technicians (EMT), paramedics, or other certified medical professionals:

• From your home, scene of an accident or medical Emergency to a Hospital
• Between Hospitals
• Between a Hospital and Skilled Nursing Facility; or
• From a Hospital or Skilled Nursing Facility to your home, if Medically Necessary 
• From a Health Care Facility to a Hospital 
• Between the Enrollee's residence and a Health Care Facility 
• Between a site of transfer and a Hospital

10% Coinsurance after Deductible

Not covered:

• A trip to a morgue or funeral home
• Any Ambulance usage for the convenience of an enrollee, family, or provider
• Ambulance transportation for member convenience or reasons that are not medically necessary

Note:  Elective air ambulance transport, including facility-to-facility transfers, requires prior approval from the Plan.

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

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

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

Outpatient Services $25 per visit

Inpatient Services $250 per visit

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

$25 per outpatient visit

$250 per inpatient visit

Inpatient services provided and billed by a hospital or other covered facility including an overnight residential treatment facility

• Room and board, such as semiprivate or intensive accommodations, general nursing care, meals and special diets, and other hospital services
• Inpatient diagnostic tests provided and billed by a hospital or other covered facility

$250 per visit

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

$25 per outpatient visit

• Custodial or domiciliary care
• Supervised living or halfway houses
• Services or care provided or billed by residential treatment center, school, or halfway house
• Custodial care center for the developmentally disabled, residential programs for drug and alcohol, or outward-bound programs, even if psychotherapy is included
• Services related to Medical Non-Compliance of care if the Enrollee ends treatment for substance abuse against the medical advice of the Provider

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

• Drugs approved by the U.S. Food and Drug Administration for which a prescription is required by Federal law, except those listed as Not covered
• Diabetic supplies limited to
  • Lancets, alcohol swabs, urine test strips/tablets, and blood glucose test strips
  • Insulin
  • Disposable needles and syringes needed to inject covered prescribed medications
• Prenatal vitamins (as covered under the plan's formulary)
• Anti Obesity drugs
• Drugs to treat gender dysphoria
  • Testosterone therapy
  • Estrogen/progesterone therapy
  • Luteinizing Hormone-Releasing Hormone (LHRH) Agonists
  • Anti-Androgens

Note: If your physician prescribes or you request a covered brand name prescription drug when a generic prescription drug equivalent is available, you will pay the difference in cost between the brand name prescription drug and the generic prescription drug equivalent, plus the applicable copayment/coinsurance unless your physician submits a preauthorization request providing clinical necessity and a medical exception is obtained.

• IU Health Retail Pharmacy

Tier 1 (Preferred Generics) - $2 copay

Tier 2 (Generics) - $5 copay

Tier 3 (Preferred Brands) - 25% Coinsurance after deductible

Tier 4 (Non-Preferred Brands and Generics) - 45% Coinsurance after deductible

Tier 5 (Specialty) - 45% up to $350 maximum per Specialty drug.

• CVS Caremark Retail Pharmacy or Mail Order Pharmacy, for up to a 30-day supply per prescription or refill:

 Tier 1 (Preferred Generics) - $3 copay

Tier 2 (Generics) - $6 copay

Tier 3 (Preferred Brands) - 30% Coinsurance after deductible

Tier 4 (Non-Preferred Brands and Generics) - 50% Coinsurance after deductible

Tier 5 (Specialty) - 50% up to $350 maximum per Specialty drug.

• Retail Pharmacy or Mail Order Pharmacy, for a 31-day up to a 90-day supply per prescription or refill:

Tier 1 (Preferred Generics) - $6 copay

Tier 2 (Generics) - $12 copay

Tier 3 (Preferred Brands) - 30% Coinsurance after deductible

Tier 4 (Non-Preferred Brands and Generics) - 50% Coinsurance after deductible

Specialty drugs limited to a 30 day supply

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

Contraceptive coverage is available at no cost to FEHB members. The contraceptive benefit includes at least one option in all methods of contraception (as well as the screening, education, counseling, and follow-up care). 

• Oral contraceptives on our formulary list
• Emergency contraception, including over-the-counter (OTC) when filled with a prescription
• Injectable contraceptives on our formulary list - four (4) vials per calendar year
• Diaphragms - one (1) per calendar year
• Condoms
• Intra Uterine Device
• Patch contraception on our formulary list

Any contraceptive that is not already available without cost sharing on the formulary can be accessed through the contraceptive exceptions process described below. 

• Members can obtain non-preferred contraceptives with zero cost-sharing through the prior authorization exception process. An exception is approved when the prescribing provider recommends a non-preferred contraceptive based on the determination of medical necessity with respect to that individual.
• Over-the-counter (OTC) contraceptives are covered at no cost if prescribed by a provider and purchased at a network pharmacy. OTC contraceptives may be processed with a valid prescription at a network pharmacy or submitted as direct member reimbursement via the CVS paper claims process and mailed directly to:  CVS Caremark, P.O. Box 52136, Phoenix, Arizona 85072-2136.

• Brand name contraceptive drugs (with generic alternatives)
• Brand name injectable contraceptive drugs such as Depo Provera (with generic alternatives) - four (4) vials per calendar year
• Brand emergency contraception (with generic alternatives)

Note:  If your physician prescribes or you request a covered brand name prescription drug when a generic prescription drug equivalent is available, you will pay the difference in cost between the brand name prescription drug and the generic prescription drug equivalent, plus the applicable copayment/coinsurance unless your physician submits a preauthorization request providing clinical necessity and a medical exception is obtained.

• IU Health Retail Pharmacy

Tier 3 (Preferred Brands) - 25% Coinsurance after deductible

Tier 4 (Non-Preferred Brands and Generics) - 45% Coinsurance after deductible

Tier 5 (Specialty) - 45% up to $350 maximum per Specialty drug.

• CVS Caremark Retail Pharmacy or Mail Order Pharmacy, for up to a 30-day supply per prescription or refill:

Tier 3 (Preferred Brands) - 30% Coinsurance after deductible

Tier 4 (Non-Preferred Brands and Generics) - 50% Coinsurance after deductible

Tier 5 (Specialty) - 50% up to $350 maximum per Specialty drug.

• Retail Pharmacy or Mail Order Pharmacy, for a 31-day up to a 90-day supply per prescription or refill:

Tier 3 (Preferred Brands) - 30% Coinsurance after deductible

Tier 4 (Non-Preferred Brands and Generics) - 50% Coinsurance after deductible

Specialty drugs limited to a 30 day supply

Specialty Medications

Specialty medications must be filled through a network specialty pharmacy.  These medications are not available through the mail order benefit.

Certain Specialty Formulary medications identified on the Specialty Drug List next to the drug name may be covered under the medical or pharmacy section of this brochure. 

Up to a 30-day supply per prescription or refill: 

• IU Health Retail Pharmacy - 45% up to $350 maximum per Specialty drug.

• CVS Caremark Retail Pharmacy or Mail Order Pharmacy, for up to a 30-day supply per prescription or refill - 50% up to $350 maximum per Specialty drug.

Oral Infertility Prescription Drugs

Note:  We cover Injectable fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit.

10% Coinsurance after Deductible, up to a combined annual limit of $20,000 for medical and prescription drugs. 

Not covered:

• Drugs available without a prescription or for which there is a nonprescription equivalent available, (i.e., an over-the-counter (OTC) drug) unless required by law.
• Drugs obtained at a non-Plan pharmacy except when related to out-of-area emergency care
• Vitamins, unless otherwise stated (including prescription vitamins), nutritional supplements, and any food item, including infant formula, medical foods and other nutritional items, even if it is the sole source of nutrition except for nutritional formulas for the treatment of phenylketonuria branched chain ketonuria, galactosemia and homocystinuria when administered under the direction of a Plan doctor (please see Durable Medical Equipment in Section 5(a)).
• Medical supplies such as dressings and antiseptics
• Lost, stolen or damaged drugs
• Drugs for cosmetic purposes
• Drugs for sexual dysfunction
• Drugs to enhance athletic performance
• Prophylactic drugs including, but not limited to, anti-malarials for travel
• Compounded bioidentical hormone replacement (BHR) therapy that includes progesterone, testosterone and/or estrogen
• Compounded thyroid hormone therapy
• Non-prescription medications unless specifically indicated elsewhere

Note:  Over-the-counter and appropriate prescription drugs approved by the FDA to treat nicotine dependence are covered under the Tobacco cessation program with a prescription. (See Section 5(a)).  OTC drugs will not be covered unless you have a prescription and that prescription is presented at the pharmacy and processed through our pharmacy claim system.

All charges

Medications to promote better health as recommended by ACA.

Drugs and supplements are covered without cost-share, which includes some over-the-counter, when prescribed by a health care professional and filled at a network pharmacy.

We will cover preventive medications in accordance with the U.S. Preventive Services Task Force (USPSTF) recommendations/guidance:

• Aspirin
• Folic acid supplements
• Oral fluoride
• Statins
• Breast cancer prevention drugs
• HIV PrEP
• Nicotine Replacement Medications (Limits apply)
• Bowel Prep Medications (Required with preventive Colonoscopy)

Please refer to the IU Health Plans formulary guide for a complete list of preventive drugs including coverage details and limitations: Preventative List

The plan also includes an expanded preventative list Expanded Preventative List

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

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

Nothing

Not covered:

• Drugs available without a prescription or for which there is a nonprescription equivalent available, (i.e., an over-the-counter (OTC) drug) unless required by law.
• Drugs obtained at a non-Plan pharmacy except when related to out-of-area emergency care
• Vitamins, unless otherwise stated (including prescription vitamins), nutritional supplements, and any food item, including infant formula, medical foods and other nutritional items, even if it is the sole source of nutrition except for nutritional formulas for the treatment of phenylketonuria branched chain ketonuria, galactosemia and homocystinuria when administered under the direction of a Plan doctor (please see Durable Medical Equipment in Section 5(a)).
• Medical supplies such as dressings and antiseptics
• Lost, stolen or damaged drugs
• Drugs for cosmetic purposes
• Drugs to enhance athletic performance
• Prophylactic drugs including, but not limited to, anti-malarials for travel
• Compounded bioidentical hormone replacement (BHR) therapy that includes progesterone, testosterone and/or estrogen
• Compounded thyroid hormone therapy
• Non-prescription medications unless specifically indicated elsewhere

Note:  Over-the-counter and appropriate prescription drugs approved by the FDA to treat nicotine dependence are covered under the Tobacco cessation program with a prescription. (See Section 5(a)).  OTC drugs will not be covered unless you have a prescription and that prescription is presented at the pharmacy and processed through our pharmacy claim system.

All charges

Coverage is limited to palliative treatment and those services listed on the following schedule.

Note: See Oral and maxillofacial surgery, section 5(b).

We have no other dental benefits. 

10% Coinsurance after Deductible

Not covered:

Dental treatment, regardless of origin or cause, except as specified elsewhere in the Group Contract. “Dental treatment” includes but is not limited to: (a) Preventive care; (b) diagnosis; (c) treatment of or related to the teeth; (d) jawbones (except that TMJ is a Covered Service); or (e) gums, including but not limited to the following

• Extraction, including removal of impacted wisdom teeth, restoration, and replacement of teeth
• Medical or surgical treatments of dental conditions
• Services to improve dental clinical outcomes

Treatment of the teeth, jawbone or gums that is required as a result of a medical condition except as expressly required by law or specifically stated as a Covered Service.

Dental implants

Dental braces

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).

The IU Health Plans Member website, our secure member self-service website, provides you with the tools and personalized information to help you manage your health. Click on website from iuhealthplans.org/memberportal to register and access a secure, personalized view of your IU Health Plans benefits.

You can:

• Review eligibility and year to date benefit use (including out of pocket and maximum totals)
• Download an electronic ID Card or request an additional paper copy
• Submit claims manually
• Review claims summaries
• Review the explanation of benefits
• Access plan documents
• Read member newsletters and our handbook

The member portal also links you to important resources such as the Find a Doctor or Facility and the My IU Health patient portal. 

If you see an IU Health provider, you can go to our My IU Health account (myiuhealth.org) to access a variety of information related ot your health and billing records.

1 Click on Create an Account. Enter personal information (name, date of birth, last four digits of your
   Social Security Number and mailing address).
2 Answer questions to verify your identity.
3 Set up security questions and answers.
4 Complete the profile by creating a username and password and submitting a valid email address.

If this process does not work for any reason, ask an IU Health team member to help you register at
your next appointment. For additional assistance with a My IU Health patient portal account, contact
the Health Information Management (HIM) team at 317.963.1661. Hours are 8 am – 5 pm ET,
Monday – Friday (excluding major holidays).

A comprehensive Help Guide can be found online at myiuhealth.org/patienthome/help-guide.

866-895-5828; TTY/TDD 711

Throughout your pregnancy journey, you can count on our team at IU Health to provide around-the-clock care. From before conception through delivery. Our IU Health hospitals offer comprehensive services for you and your baby. We'll answer you questions and address any pregnancy or birth concerns. To view information please visit iuhealth.org/maternity

Clickotine is a smartphone (iPhone, Android, etc.) application that provides an individualized eight-week smoking cessation program. Features include personalized messaging, medication reminders, digital diversions, optional nicotine replacement therapy (NRT) distribution and coaching via the telephone quit line. Clickotine is available at no cost to IU Health Plans members. Go to the app store on your mobile device, search for Clickotine and download. Follow the on-screen instructions and enter the code 9CEB4A. If you have questions, email support@clickotine.com.

If you have a medical issue while away from home, please contact your doctor first. He or she will be able to offer help with routine or urgent care questions. In the event of a true emergency, IU Health Plans covers emergency care services. 

For assistance in finding a provider outside of Indiana, contact First Health by calling 800.226.5116 or visit myfirsthealth.com.

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 866-895-5828 or at our website at www.iuhealthplans.org.

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 medical, hospital and vision claims to: Indiana University Health Plans, PO Box 11196 Portland, ME 04104-7196.

Submit your pharmacy claims to: CVS Caremark, P.O. Box 52136, Phoenix, Arizona 85072-2136.

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.  Once we pay benefits, there is a three-year limitation on the reissuance of uncashed checks.

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

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

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

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

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:  Attention: Appeals, IU Health Plans, 950 N Meridian Street, Suite 400, Indianapolis, IN 46204; 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, 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.

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

a) Pay the claim or

b) Write to you and maintain our denial or

c) Ask you or your provider for more information

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

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

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

You must write to OPM within:

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

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, 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.

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 866-895-5828.  We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal.  You may call OPM’s Health Insurance x at 202 606-0737 between 8 a.m. and 5 p.m. Eastern Time.

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

You must tell us if you or a covered family member has coverage under any other health plan or has automobile insurance that pays 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.iuhealthplans.org. 

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 allowed amount. 

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.

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.

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.

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

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 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.

·    Research costs – costs related to conducting the clinical trial such as research physician and nurse time, analysis of results, and clinical tests performed only for research purposes.  These costs are generally covered by the clinical trials.  This plan does not cover these costs.

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

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

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

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

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

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

When Original Medicare is the primary payor, Medicare processes your claim first.  In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges.  To find out if you need to do something to file your claim, call us at 866-895-5828 or see our website at www.iuhealthplans.org.

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

Please review the following examples which 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.  

Benefit Description: Deductible
High Option You pay without Medicare: $250 self only/ $500 family
High Option You pay with Medicare Part B: $250 self only/ $500 family

Benefit Description: Catastrophic Protection Out-of-Pocket Maximum
High Option You pay without Medicare: $6,000 self only/$12,000 family
High Option You pay with Medicare Part B: $6,000 self only/$12,000 family

Benefit Description: Part B Premium Reimbursement Offered
High Option You receive without Medicare: $0
High Option You receive with Medicare Part B: $0

Benefit Description: Primary Care Physician
High Option You pay without Medicare: $25 Copayment per visit
High Option You pay with Medicare Part B: $25 Copayment per visit

Benefit Description: Specialist
High Option You pay without Medicare: $35 Copayment per visit
High Option You pay with Medicare Part B: $35 Copayment per visit

Benefit Description: Inpatient Hospital
High Option You pay without Medicare: $150 Copayment per visit
High Option You pay with Medicare Part B: $150 Copayment per visit

Benefit Description: Outpatient Hospital
High Option You pay without Medicare: $100 Copayment per visit
High Option You pay with Medicare Part B: $100 Copayment per visit

Benefit Description: Incentives offered
High Option You receive without Medicare: $0
High Option You receive with Medicare Part B: $0

 You can find more information about how our plan coordinates benefits with Medicare in our Benefits Guide at www.iuhealthplans.org.

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

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

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

This Plan and our Medicare Advantage plan: 

This Plan and another plan’s Medicare Advantage plan:  You may enroll in another plan’s Medicare Advantage plan and also remain enrolled in our FEHB plan.  We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s network and/or service area (if you use our Plan providers).  

However, we will not waive any of our copayments, coinsurance, or deductibles.  If you enroll in a Medicare Advantage plan, tell us.  We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

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

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)

The Patient Protection and Affordable Care Act, Public Law 111- 148, as amended by the Healthcare and Education Reconciliation Act, Public Law 111-152, collectively referred to as the Affordable Care Act or ACA.

The amount a Participating Provider has agreed to accept as payment in full for the provision of Covered Services.

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.

See Section 4.

See Section 4.

Health Care Services primarily intended to preserve, change or improve the Enrollee’s appearance or are furnished for psychiatric or psychological reasons.

See Section 4.

Health Care Services performed, prescribed, directed or authorized by a Provider and for which the Group Contract provides Benefits. To be a Covered Service, the Health Care Service must be all of the following:

• Medically Necessary.
• Within the scope of the license of the Provider.
• Rendered while coverage under the Group Contract is in force.
• Not experimental/investigative.
• Authorized in advance by us if Precertification is required under the Group Contract.
• Not excluded or limited by the Group Contract.

Any type of care provided according to Medicare guidelines, including Nonskilled, personal care, such as help with activities of daily living like bathing, dressing, eating, getting in or out of a bed or chair, moving round, and using the bathroom. It may also include care that most people do themselves, like using eye drops. In most cases, Medicare doesn't pay for custodial care. Custodial care is not covered.

See Section 4.

An individual you have appointed to assist or represent you with a Grievance, Appeal, or External Review.  This person may include Providers, attorneys, friends, or family members.  You must identify your Designated Representative to us in writing in order to prevent disclosure of your medical information to unauthorized persons. If you would like to designate a representative, you will need to complete a Designation of Representation form. The form is available online at iuhealthplans.org or, upon your request, we will forward a form to you for completion.  If we do not obtain a completed Designation of Representation form, we will proceed in our investigation of your Grievance, Appeal or External Review, however, all communication related to such review will be directed to you and we will respond to inquiries submitted by you only.

With respect to an Emergency Medical Condition, a medical screening examination that is within the capability of the Emergency department of a Hospital or a Freestanding Independent Emergency Department, including ancillary services routinely available to the Emergency department to evaluate such Emergency Medical Condition and within the capabilities of the staff and facilities available at the Hospital or Independent Freestanding Emergency Department, and such further medical examination and treatment to stabilize the patient. The term “stabilize” means, with respect to an Emergency Medical Condition, to provide such medical treatment of the condition as may be necessary to assure, within reasonable medical probability that no material deterioration of the condition is likely to result from or occur during the transfer of the individual from a facility. With respect to a pregnant person who is having contractions, the term “stabilize” also includes the delivery (including the placenta) if there is inadequate time to effect a safe transfer to another Hospital before delivery or a transfer may pose a threat to the health or safety of the pregnant person or the unborn Child.

We will deem any drug, biologic, device, Diagnostic, product, equipment, procedure, treatment, service, or supply to be Experimental/Investigative if we determine that one or more of the following criteria apply when the Health Care Service is rendered with respect to the use for which benefits are sought. The drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply satisfies any or all of the following listed below:

• Cannot be legally marketed in the United States without the final approval of the FDA, or other licensing or regulatory agency, and such final approval has not been
• Has been determined by the FDA to be contraindicated for the specific use.
• Is provided as part of a clinical research protocol or clinical trial or is provided in any other manner that is intended to evaluate the safety, toxicity, or efficacy of the drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or
• Is subject to review and approval of an Institutional Review Board (IRB) or other body serving a similar
• Is provided pursuant to informed consent documents that describe the drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply as Experimental/Investigative, or otherwise indicate that the safety, toxicity, or efficacy of the drug, biologic, device, diagnostic, product, equipment, procedure, treatment, service, or supply is under evaluation.

A medical condition, including a mental health condition or substance abuse disorder. that arises suddenly and unexpectedly and manifesting itself by acute symptoms of such severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine to result in any of the following:

• Placing a person’s health (or, with respect to a pregnant person, the health of such pregnant person or the unborn Child of the pregnant person) in serious jeopardy.
• Serious impairment to a person’s bodily functions.
• Serious dysfunction of a bodily organ or part of a person.

The entity to which the Group Contract has been issued.

the Subscriber or any Dependent:

• Who meets all applicable eligibility requirements for coverage under the Group Contract;
• Who is enrolled as provided in the Contract; and,
• For whom the required premium payment has been received by us.

Enrollees are also referred to as “you” and “your” in this Evidence of Coverage.

The contract between Indiana University Health Plans, Inc. and the Employer that provides Benefits for Covered Services for Subscribers and enrolled Dependents. The Group Contract consists of the Evidence of Coverage, the Schedule of Benefits and any amendments or riders to any of these documents. The Summary of Benefits and Coverage and marketing materials are not considered a part of the Group Contract.

Medical or health care services, including services for Behavioral Health, whether or not covered under the Group Contract, which include but are not limited to: medical evaluations, diagnoses, treatments, procedures, drugs, therapies, devices and supplies.

An institution that is operated and licensed under law and is primarily engaged in providing Health Care Services on an Inpatient basis.

Receipt of Health Care Services as a registered bed patient in a Hospital or other Provider where room and board charge is made.

Medical Food is a food that is Medically Necessary and prescribed by a Provider for the treatment of an inherited metabolic disease or inherited metabolic disorders for the primary or sole source of nutrition. Medical Food means a formula that is intended for the dietary treatment of a disease or condition for which nutritional requirements are established by medical evaluation and formulated to be consumed or administered enterally under the direction of a physician.

Those Health Care Services that we determine to be all of the following:

• Clinically appropriate in terms of type, frequency, extent, site and duration and considered effective for the Enrollee’s illness, injury or disease.
• Required for the direct care and treatment or management of the Enrollee’s illness, injury or disease.
• If not provided, the Enrollee’s condition would be adversely affected.
• Provided in accordance with generally accepted standards of medical practice.
• Not primarily for the convenience of the Enrollee, the Enrollee’s family, the physician or another prescribing Provider.
• Not more costly than an alternative service or sequence of services at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the Enrollee’s illness, injury or disease.

We will decide whether a Health Care Service is Medically Necessary.  We will base our decision in part on a review of the Enrollee’s medical records and will also consider reports in peer reviewed medical literature, reports and guidelines published by nationally recognized health care organizations that include supporting scientific data, professional standards of safety and effectiveness, which are generally recognized in the United States for diagnosis, care or treatment, the opinion of health professionals in the generally recognized health specialty involved, the opinion of the attending physicians and other medical Providers, which have credence but do not override contrary opinions and any other relevant information brought to our attention.

The definition of Medically Necessary under the Group Contract relates only to coverage and may differ from the way a Provider engaged in the practice of medicine may use the term. The fact that a Provider has furnished, prescribed, ordered, recommended or approved the Health Care Service does not make it Medically Necessary or mean that we must provide coverage for it.

Any of the following types of coverage.

• Government Sponsored programs (such as Medicaid, Medicare, CHIP, Veteran’s health care programs, Refugee Medical Assistance and student health coverage).
• An Employer sponsored health benefit plan.
• Individual health coverage.
• State health benefits high risk pool.
• Other programs recognized by the U.S. Department of Health and Human Services as Minimum Essential Coverage. 

Health Care Services that are not covered under the terms of the Group Contract.

A Provider that has not entered into a contractual agreement with us or is not otherwise engaged by us to provide Health Care Services to Enrollees under the Group Contract.

Receipt of Health Care Services while not an Inpatient.

The maximum amount Enrollees will pay for Covered Services in a Calendar Year.  The Out-of-Pocket Maximum includes the Deductible, Copayments and Coinsurance Percentage. The Out-of-Pocket Maximum is shown in the Schedule of Benefits and applies as follows:

• The “Per Enrollee” Out-of-Pocket Maximum is the amount that must be satisfied by each Enrollee, except as provided under the “Per Family” Out-of-Pocket Maximum provision.
• The “Per Family” Out-of-Pocket Maximum is the maximum Out-of-Pocket amount that applies if the Subscriber has Family Coverage. Each Enrollee can satisfy the entire “Per Enrollee” Out-of-Pocket Maximum until the total “Per Family” Out-of-Pocket Maximum is met for the Calendar Year. The “Per Enrollee” Out-of-Pocket amounts accumulate until the “Per Family” Out-of-Pocket Maximum is satisfied. The “Per Family” Out-of-Pocket Maximum can be satisfied by any combination of Cost Sharing paid by or for the Enrollees. At no time will the combined ”Per Enrollee” Out-of-Pocket Maximum amounts exceed the “Per Family” Out-of-Pocket Maximum.

A Provider that has entered into a contractual agreement or is otherwise engaged by us or another Provider that has an agreement with us to provide Health Care Services to Enrollees under the Group Contract.

Any claims that are not pre-service claims.  In other words, post-service claims are those claims were treatment has been performed and the claims have been sent to us in order to apply for benefits.

Those claims (1) that require precertification, prior approval, or a referral and (2) where failure to obtain precertification, prior approval, or a referral results in a reduction of benefits.

A required review of a Health Care Service for a Benefit coverage determination which must be done prior to the Health Care Service start date.

A Participating Provider practicing and duly licensed as a physician practicing in family practice, internal medicine, gynecology, obstetrics or pediatrics and who has agreed to assume primary responsibility for managing the Enrollee’s medical care under the Group Contract.

A doctor, Hospital, pharmacy, or other health care institution or practitioner licensed, certified or otherwise authorized to provide Health Care Services pursuant to the law of the jurisdiction in which care or treatment is received including but not limited to an Independent Freestanding Emergency Department.

The cost of Medically Necessary Health Care Services related to the care method that is under evaluation in an Approved Clinical Trial. Routine Care Costs do not  include any of the following:

• The Health Care Service that is the subject of the Approved Clinical Trial.
• Any treatment modality that is not part of the usual and customary standard of care required to administer or support the Health Care Service that is the subject of the Approved Clinical Trial.
• Any Health Care Service provided solely to satisfy data collection and analysis needs that are not used in the direct clinical management of the patient.
• An investigational drug or device that has not been approved for market by the federal Food and Drug Administration.
• Transportation, lodging, food, or other expenses for the patient or a family member or companion of the patient that is associated with travel to or from a facility where an Approved Clinical Trial is conducted.
• A Health Care Service that is provided by the sponsor of the Approved Clinical Trial free of charge for any new patient.
• A Health Care Service that is eligible for reimbursement from a source other than this Group Contract, including the sponsor of the Approved Clinical Trial.

In the case of an acute illness, a condition that is serious enough to require specialized medical treatment to avoid the reasonable possibility of death or permanent harm. In the case of a chronic illness or condition, a condition that is:

(1) life-threatening, degenerative, potentially disabling, or congenital; and

(2) requires specialized medical care over a prolonged period of time.

A Provider licensed under state law to provide Inpatient care for recovery from a Sickness or injury, supervised by a physician, providing 24 hour per day nursing care supervised by a full-time registered nurse, and not primarily custodial or domiciliary care.

A protocol that sets forth an order in which certain Prescription Drugs must be used to treat an Enrollee’s condition.

An employee of the Employer who is eligible for and enrolled in coverage under the Group Contract.

Health Care Services delivered by use of interactive electronic communications and technology in compliance with the federal Health Insurance Portability and Accountability Act (HIPAA), including:

1. Secure video conferencing;
2. Store and forward technology;
3. Remote patient monitoring technology;

Between a Participating Provider in one location and a patient in another location and this is identified by us as secure and appropriate for use in the delivery of certain Health Care Services including, medical exams and consultations and Behavioral Health evaluations and treatment. 

For purposes of this definition, “store and forward technology” means transferring data from one site to another through the use of a camera or similar device that records (stores) an image that is sent (forwarded) via telecommunication to another site for consultation.

A request for a Health Care Service that, if subject to the time limits applicable to Post-Service Claims or Pre-Service Claims (as defined in Article 7 Section B) meets either of the following:

• Would seriously jeopardize the Enrollee’s life, health or ability to reach and maintain maximum function.
• In the opinion of physicians familiar with the Enrollee’s condition, would subject the Enrollee to severe pain that cannot be adequately managed unless we approve the Claim.

Indiana University Health Plans, Inc. 

The term “you” refers to you, the Subscriber. The term “Enrollee” refers to you, the Subscriber and your Dependents who are enrolled for coverage under the Group Contract.  

Office visit copay: $25 primary care; $35 specialist

25

 $250 Copayment per visit

47

$100 Copayment per visit

48

$250 Copayment.  Waived if admitted. 

51

$250 Copayment.  

51

• $25 copayment per visit
• $35 Copayment per visit
• $250 Copayment per visit
• 10% Coinsurance after Deductible
• $25 Copayment per visit

53

Retail (30-day supply)
• Tier 1 – (Preferred Generic) - $2 copayment when using IU Pharmacy
$3 copayment when using CVS Caremark Advance Choice Pharmacies
• Tier 2 – (Non-Preferred Generic) - $5 copayment when using IU Pharmacy
$6 copayment when using CVS Caremark Advance Choice Pharmacies
• Tier 3 – (Preferred Brand Name) – 25% coinsurance after the deductible using IU Pharmacy, 30% coinsurance after the deductible using CVS Caremark Advanced Choice Pharmacies
• Tier 4 – (Non-Preferred Brand Name) – 45% coinsurance after the deductible using IU Pharmacy, 50% coinsurance after the deductible using CVS Caremark Advanced Choice Pharmacies
• Tier 5 – (Specialty) – 45% coinsurance after the deductible. Limited to a 30-day supply.

Maintenance (90-day supply)
• Tier 1 (Preferred Generic) - $6 copayment using IU Pharmacy or CVS Caremark Advanced Choice Pharmacies
• Tier 2 (Non-Preferred Generic) - $12 copayment using IU Pharmacy or CVS Caremark Advanced Choice Pharmacies
• Tier 3 (Preferred Brand Name) – 30% coinsurance after the deductible using IU Pharmacy or CVS Caremark Advanced Choice Pharmacies
• Tier 4 (Non-Preferred Brand Name) – 50% coinsurance after the deductible using IU Pharmacy or CVS Caremark Advanced Choice Pharmacies

57

10% Coinsurance after Deductible

62

Pediatric vision, members pay nothing. Limited to one exam per calendar year. Treatment and supplies following surgery for cataracts, contact lenses or glasses (including bifocals) are covered. All other treatment and supplies are not covered.

32

Contact Plan at 866-895-5828

63

Nothing after $6,000/Self Only enrollment or $12,000/ Self Plus One or Self and Family enrollment per year.
Some costs do not count toward this protection.

13