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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Newborns of covered children are insured only for routine nursery care during the covered portion of the mother’s maternity stay.
You can find additional information at www.opm.gov/healthcare-insurance.

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 doesn’t 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 paid according to the 2024 benefits of your prior plan or option.    If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2023 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

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

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

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

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

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

If you were married to an enrollee and your divorce or annulment is final, you may not remain covered as a family member under your former spouse’s enrollment. This is the case even when the court has ordered your former spouse to provide health coverage for you. However, you may be eligible for your own FEHB coverage under either the spouse equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get information about your coverage choices. You can also visit OPM’s website at
www.opm.gov/healthcare-insurance/life-events/memy-family/im-separated-or-im-getting-divorced/#url=Health.  We may request that you verify the eligibility of any or all family members listed as covered under the enrollee's FEHB enrollment.

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

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

Enrolling in TCC. Get the RI 79-27, which describes TCC, from your employing or retirement office or from www.opm.gov/healthcare-insurance/healthcare/plan-information/guides. 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.

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

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed, and your coverage will not be limited due to pre-existing conditions.  When you contact us, we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act’s Health Insurance Marketplace in your state. For assistance in finding coverage, please contact us at 800-741-4825 or visit or website at
www.sentarahealthplans.com/federal

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.

Sentara Health Plans offers Open Access to our members within the Plan’s service area identified on page 14. You can go directly to any network specialist for covered services without a referral from your primary care provider (PCP). Whether your covered services are provided by your primary care physician (for your PCP copay) or by any other participating provider in the network (for the specialist copay), you will be responsible for payment which may be in the form of a copay (flat dollar amount) or coinsurance (a percentage of covered expenses). You still must select a PCP and notify member services of your selection. If you go directly to a specialist, you are responsible for verifying that the specialist is participating in the Plan. There are three ways you can check to see if your specialty provider is in the Plan’s network. You can call Member Services, you can check your provider directory, or you can log onto the Plan’s website at
www.sentarahealthplans.com/federal to verify that your specialty provider is in the Plan’s network. Please remember that although you do not need a referral for specialty care some services, supplies, and drugs require precertification. Please refer to Section 3 for precertification information and to make sure which services require precertification.

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 757-552-7550 or 800-206-1060 or write to us at Sentara Health Plans, PO Box 66189, Virginia Beach, VA 23466.  You may also request replacement cards through our website at
www.sentarahealtlhplans.com/federal.

If you use our Plan you can receive covered services from a participating provider without a required referral from your primary care provider or by another participating provider in the network.  You will not have to file claims.

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

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

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

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

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

This Plan provides Care Coordinators for complex conditions and can be reached at 757-552-7550 or 800-206-1060 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, or you can call Member Services to find out if a hospital or other facility is a participating provider. The list is also on our web site.

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

Your primary care provider can be a family practitioner, internist or pediatrician. Your primary care provider will provide most of your healthcare or refer you to see a specialist.

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

You do not need a referral from your primary care provider (PCP) for specialty care from a Plan provider.

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

• If you are seeing a specialist when you enroll in our Plan, you must make sure that they participate with us. 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, you may receive services from your current specialist until we can make arrangements for you to see someone else.
• If you have a chronic and disabling condition and lose access to your specialist because we:
  • terminate our contract with your specialist for other than cause; or
  • drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB program plan; or
  • reduce our Service Area and you enroll in another FEHB plan;

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

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

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

We pay for covered services from the effective date of your enrollment.  However, if you are in the hospital when your enrollment in our Plan begins, call Member Services immediately at 757-552-7550 or 800-206-1060.  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; or
• the day your benefits from your former Plan run out; or
• the 92^nd day after you become a member of this Plan, whichever happens first.

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

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

You must get prior approval for certain services.  Your benefits for Covered Services may be reduced or denied if you do not comply with the Plan's precertification requirements.

For certain services your provider must obtain prior approval from us.  Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice.  You must obtain precertification for:  

• Transplants,
• scheduled ambulance transport,
• outpatient surgery and services,
• inpatient facility admission,
• mental health and substance use disorder services, including:
  • Partial Hospitalization
  • Residential Treatment
  • Intensive Outpatient Programs (IOP)
  • Transcranial Magnetic Stimulation (TMS)
  • Electro-convulsive therapy
• durable medical equipment,
• hearing aids,
• artificial limbs,
• prosthetic and orthopedic appliances,
• home health care services,
• skilled nursing facility care,
• physical therapy, occupational therapy, speech therapy,
• cardiac rehabilitation,
• pulmonary rehabilitation, vascular rehabilitation, vestibular rehabilitation,
• early intervention services,
• clinical trials,
• hospice services,
• oral surgery,
• TMJ services, 
• mental health services,
• growth hormone therapy,
• maternity services, 
• Magnetic Resonance Imaging (MRI), Computerized Axial Tomography (CT) Scans, 
• chemotherapy services, chemotherapy drugs and radiation therapy,
• sleep studies performed in a facility,
• infertility services
• services from non-Plan providers, and,
• certain prescription drugs.

First, your physician, your hospital, you, or your representative, must call us at 757-552-7550 or 800-206-1060 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 of requested for hospital stay.

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

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

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

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

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

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM.  Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 757-552-7550.  You may also call OPM’s FEHB 2 at 202-606-3818 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 757-552-7550 or 800-206-1060. 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.

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

Note: When a newborn requires definitive treatment during or after the mother’s hospital stay, the newborn is considered a patient in their own right. If the newborn is eligible for coverage, regular medical or surgical benefits apply rather than maternity benefits.

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

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 757-552-7550 or 800-206-1060.

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. 

Cost-sharing  is the general term used to refer to your out-of-pocket costs (e.g. coinsurance, and copayments) for the covered care you receive.

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

Example:  When you see your primary care provider you pay a copayment of $25 per office visit, and $55 per specialist office visit.

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

This Plan does not have a deductible.

Coinsurance is the percentage of our allowance that you must pay for your care.  

Example: In our Plan, you pay 30% 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.

With the High Option, after your (copayments and coinsurance) total $5,500 per person regardless of enrollment tier and will not exceed more than $11,000 combined per Self Plus One or $11,000 combined for Self Plus Family enrollment in any calendar year, you do not have to pay any more for covered services.  However, copayments and coinsurance for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copayments/coinsurance for these services:

• Balance-billed charges
• Healthcare charges this plan does not cover
• Precertification penalties
• Infertility drugs and procedures
• Premiums

We will notify you when you reach the maximum.

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 old plan will first apply your covered out-of-pocket expenses until the prior year's catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan.  Your prior plan will pay these covered expenses according to this year’s benefits; benefit changes are effective January 1.

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

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

A surprise bill is an unexpected bill you receive for:

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

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

Your health plan must comply with the NSA protections that hold you harmless from surprise bills. In addition, your health plan adopts and complies with the surprise billing laws of Virginia and § 38.2-3445.01. For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.sentarahealthplans.com/federal or contact the health plan at 757-552-7550 or 800-206-1060.

• 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.

• $25 copayment for primary care provider office visits
• $55 copayment for specialist office visits
• No copayment for primary care provider office visits for preventive care
• No referral needed to see a specialist
• $10 copayment for Tier 1 prescription drugs
• Protection against catostrophic costs (out of pocket maximum) is $5,500 for Self Only or $11,000 for Self Plus One or Self Plus Family enrollment per year 

Professional services of physicians

• In physician’s office
• Office medical consultation
• Second surgical opinion
• Advance care planning

$25 copayment per visit to your primary care provider

$55 copayment per visit to a specialist  

Professional services of physicians

• During a hospital stay
• In a skilled nursing facility

20% coinsurance of our Plan allowance

Professional services of physicians

• In an Urgent Care Center

$55 copayment per visit 

• MDLIVE Virtual Office Visit

How to get started?

• Sign in to your member portal at www.sentarahealthplans.com and select Access MDLIVE, or call 866-648-3638.
• Have your Sentara Health Plans member ID number available to register. Please note that you’ll need to create an account for each covered member of your family over the age of two.
• When you want to see a doctor, you can go online to request immediate access to a provider on-call via phone or schedule a time at your convenience. You can also get connected by calling 866-648-3638.

Nothing

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine Pap test
• Pathology
• X-ray
• Non-routine mammogram
• CT Scan
• MRI
• Ultrasound
• Electrocardiogram and EEG

20% coinsurance of our Plan allowance

Routine physical every 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/Tdap, and human papillomavirus (HPV). For a complete list of immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/
• Screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at https://shorturl.at/hovHM
• Individual counseling on prevention and reducing health risks.
• Preventive care benefits for woman 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 services for woman please go to the Health and Human Services (HHS) website at
  https://www.healthcare.gov/preventive-care-women/
• Routine mammogram 
• 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 and coinsurance.

• Medical Nutrition Therapy and Intensive Behavioral Therapy for the prevention of obesity related comorbidities as recommended under the U.S. Preventive Services Task Force (USPSTF) A and B recommendations.

Nothing 

Not covered:

• Physical exams required for obtaining or continuing employment or insurance, attending schools or camp, or travel.
• Immunizations, boosters, and medications for travel or work-related expenses.
• Care and services from non-Plan providers unless precertified by the Plan prior to receiving this service.

All charges

• Well-child visits, examinations, and immunizations other preventive recommended services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to https://brightfutures.aap.org
• Immunizations such as DTaP/Tdap, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the Centers for Disease Control (CDC) website at
  https://www.cdc.gov/vaccines/schedules/index.html
• You can also find a complete list of preventive care services recommended under the U.S. Preventive Services Task Force (USPSTF) online at https://shorturl.at/hovHM

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 listing of services will be subject to the applicable member copayments and coinsurance.

Nothing 

• Hearing services (testing, treatment, and supplies) for children
  • "Hearing Aid" means any wearable, non-disposable instrument or device designed or offered to aid or compensate for impaired human hearing and any parts, attachments, or accessories, including earmolds, but excluding batteries and cords. Hearing aids are not to be considered durable medical equipment.
  • Coverage includes hearing aids and related services for children 18 years of age or younger. Coverage is limited to the cost of one hearing aid per hearing-impaired ear every 24 months, up to $1,500 per hearing aid. Members may choose a higher-priced hearing aid and pay the difference.
    
    • "Related Services" includes earmolds, initial batteries, and other necessary equipment, maintenance, and adaptation training.
    • Coverage is limited to services and equipment recommended by an otolaryngologist (ENT) and provided or dispensed by an otolaryngologist (ENT), licensed audiologist, or licensed hearing aid specialist.

Note: Pre-certification is required.

Nothing

Complete maternity (obstetrical) care, such as:

• Prenatal and postpartum care 
• Screening for gestational diabetes 
• Breastfeeding support, supplies and counseling for each birth
• Screening and counseling for prenatal and postpartum depression

Nothing 

• Delivery

$450 Global Copayment

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 stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. 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.
• Hospitalization 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:

• Routine care and services for pregnancy outside the Plan’s service area.
• Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service.

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.  *Generic oral contraceptives are eligible for 100 percent coverage and no cost share to members.  Brand name oral contraceptives will be covered based on the plan’s formulary and the appropriate Copayment or Coinsurance will apply based on the drug tier.  Please visit www.express-scripts.com/frontend/open-enrollment/ohpcomm to determine member cost share for brand name oral contraceptives. 

Nothing 

Voluntary sterilization (See Surgical Procedures Section 5 (b))

$55 copayment

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic testing and counseling that is determined to be not medically necessary. 
• Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service.

Infertility is defined as failure to achieve pregnancy within 12 months of unprotected intercourse or therapeutic donor insemination in an individual younger than 35 years or, for an individual 35 years and older, within 6 months. Infertility may also be established through an evaluation based on medical history and diagnostic testing.

Diagnosis and treatment of infertility:

• Artificial insemination-Limited to 3 per year
  • Intravaginal insemination (IVI)
  • Intracervical insemination (ICI)
  • Intrauterine insemination (IUI)
• Endometrial biopsies-Limited to 1 per year 
• Semen analysis - Limited to 2 per year
• Hysterosalpingography -Limited to 2 per year
• Sims-Huhner test (smear) - Limited to 2 per year
• Diagnostic laparoscopy -Limited to 1 per year
• Infertility Drugs - See Section5(f) 

Note: IVF drugs and infertility drugs under this rider will not count toward your Maximum Out-of-Pocket Amount.

Cost sharing is determined by the type and place of service.

Cryopreservation for egg or sperm for persons facing the possibility of iatrogenic infertility, including infertility associated with gender affirming surgery.

• Includes short-term storage coverage while the member is undergoing therapy (up to 12 months)
  • Benefits are not available for embryo fertilization or transfer
  • Benefits are not available for long-term storage costs (greater than one year)
  • Benefits are further limited to one cycle of fertility preservation for Iatrogenic Infertility per covered person during the entire period of time member is enrolled for coverage under the policy (i.e. 1 attempt at harvesting gametes).

20% coinsurance of our Plan allowance

Not covered:

• Infertility services after voluntary sterilization
• donor egg, and any other programs not listed as a covered service
• reproductive material storage
• any treatment related to sexual organ function, dysfunction, or inadequacies, including but not limited to impotency

All charges

• Testing and treatment
• Allergy injections
• Allergy serum

$25 copayment per visit to your primary care provider

$55 copayment per visit to a specialist 

Not covered:

• Provocative food testing and sublingual allergy desensitization
• Food allergy ingestion testing
• Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service

• 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
• Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy
• Growth hormone therapy (GHT)

Note: Growth hormone is covered under the prescription drug benefit.  We only cover GHT when we precertify the treatment.  We will ask you to submit information that establishes that the GHT is medically necessary.  Ask us to precertify GHT before you begin treatment.  We will only cover GHT services and related services and supplies that we determine are medically necessary.  See Other Services under You Need Prior Plan Approval for certain services.

20% coinsurance of our Plan allowance

• Cardiac rehabilitation following a qualifying event/condition is provided for up to 90 consecutive days from the start of rehabilitation.

20% coinsurance of our Plan allowance, during inpatient admission

• Pulmonary, vascular, and vestibular rehabilitation is covered for up to 90 consecutive days from the start of rehabilitation.

20% coinsurance of our Plan allowance, during inpatient admission

• Dialysis – hemodialysis and peritoneal dialysis

20% coinsurance of our Plan allowance

Applied Behavior Analysis (ABA) - Members with autism spectrum disorder

Covered Services include “diagnosis” and “treatment” of Autism Spectrum Disorder.

“Autism Spectrum Disorder” means any pervasive developmental disorder, including (i) autistic disorder, (ii) Asperger's Syndrome, (iii) Rett syndrome, (iv) childhood disintegrative disorder, or (v) Pervasive Developmental Disorder – Not Otherwise Specified, as defined in the most recent edition of The Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association.  

“Diagnosis of autism spectrum disorder” means medically necessary assessments, evaluations, or tests to diagnose whether an individual has an autism spectrum disorder.

“Treatment for autism spectrum disorder” shall be identified in a treatment plan and included the following care prescribed or ordered for an individual diagnosed with autism spectrum disorder by a licensed physician or a licensed psychologist who determines the care to be medically necessary: (i) behavioral health treatment, (ii) pharmacy care, (iii) psychiatric care, (iv) psychological care, (v) therapeutic care, and (vi) applied behavioral analysis when provided or supervised by a board certified behavioral analyst licensed by the Board of Medicine. No limit on visits.

“Applied behavioral analysis” means the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior. 

Cost sharing determined by the type and place of service.

Not covered:

• Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service

All charges

• Qualified physical therapists 
• Occupational therapists

Coverage will include 30 rehabilitative combined physical therapy and occupational therapy visits per year and 30 habilitative combined physical therapy and occupational therapy visits per year.

Note: For mental health conditions or substance use disorders visit limits will not apply.

Note: Precertification is required. 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.

20% coinsurance of our Plan allowance

Early Intervention Services are covered for children from birth to age three for medically necessary services limited to:

• speech, language, occupational and physical therapy
• assistive technology services and devices

Note: Covered services are provided to enhance functional ability without effecting a cure. Department of Mental Health, Mental Retardation, and Substance Abuse Services must certify dependents as eligible for services under Part H of the Individuals with Disabilities Act.

Note: Precertification is required. See Section 3.

Cost sharing determined by the type and place of service.

Not covered:

• Long-term rehabilitative therapy
•  Therapies available in a school program or available through state and local funding, including sign language therapies
• Recreation therapies, including art, dance, or  music therapies
• Sleep therapies
• Exercise programs, or equine therapies
• Driver evaluations as part of occupational therapy
• Driver training
• Functional capacity testing needed to return to work
• Any service or supply, unless provided in accordance with a specific treatment plan pre-authorized by the Plan
• Therapy which is primarily educational in nature, special education, or sign language
• Work-hardening programs
• Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service

Speech therapy is covered for up to 30 rehabilitative speech therapy visits per year; up to 30 habilitative speech therapy visits per year for medically necessary treatment.

Note: For mental health conditions or substance use disorders visit limits will not apply.

20% coinsurance of our Plan allowance

Not covered:

• Speech therapy not precertified by the Plan as part of a specific treatment plan
• Care and services from non-Plan providers unless precertifed by the Plan prior to receiving the service

• 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.

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

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

$25 copayment per primary care provider office visit 

$55 copayment per specialist office visit 

Not covered:

• All other hearing testing for adults
• Hearing aids, testing and examinations for adults
• Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service

Preventive vision care and services are administered by Vision Service Plan (VSP).  The following services are covered once every 12 months: 

• Annual eye refraction including care history, visual acuity test for glasses and written lens prescription.

• Screening tests for diseases or abnormalities, including glaucoma and cataracts.

Note: You should select a Vision Service Provider and call him or her directly to schedule an appointment.  If you need help or a current list of participating providers, call Sentara Health Plans at 757-552-7550 or 800-206-1060, or visit www.sentarahealthplans.com.  

Nothing

• One pair of eyeglasses or contact lenses (up to $200 allowance) to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts).   Please note that New technology, intraocular lens are excluded from coverage.

Nothing 

• Eye exam to determine the need for vision correction for children up to age 22 (see Preventive care, children)

Nothing per primary care provider office visit 

$55 copayment per specialist office visit 

Not covered:

• Eyeglasses or contact lenses 
• Eye exercises and orthoptics
• Radial keratotomy and other refractive surgery
• Any eye examination, or any corrective eyeware required by an employer as a condition as employment
• Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service

$25 copayment per primary care provider office visit 

$55 copayment per specialist office visit 

Not covered:

• Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the  foot, except as stated above
• Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery) 
• Foot orthotics of any kind including customized or non-customized shoes, boots, and inserts, except as medically necessary and approved by the Plan for members with diabetes
• Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service

• Artificial limbs and eyes
• Prosthetic sleeve or sock
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome
• Implanted hearing-related devices, such as bone anchored hearing aids (BAHA) and cochlear implants
• Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy.
• Lenses following cataract removal
• Repair and replacement

Note: For information on the professional charges for the surgery to insert an implant, see Section 5(b) Surgical Procedures.  For information on the hospital and/or ambulatory surgery center benefits, see Section 5(c) Services Provided by a Hospital or Other Facility, and Ambulance Services.

30% coinsurance of our Plan allowance

Not covered:

• Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service

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

• Oxygen
• Dialysis equipment
• Hospital beds
• Standard non-motorized wheelchairs
• Crutches
• Walkers
• Colostomy, iliostomy, and tracheostomy supplies
• Suction and urinary catheters
• Formula and enteral nutrition products that are prescribed for a inherited metabolic disorder

Note: When your Plan physician prescribes this equipment we will arrange with a healthcare provider to rent or sell you durable medical equipment at discounted rates.

30% coinsurance of our Plan allowance

• Diabetic supplies and equipment including prescribed by a Plan physician for insulin dependent, gestational, and non-insulin dependent diabetics.

Precertification is required for insulin pumps and pump infusion sets and supplies.

Coverage includes benefits for FDA-approved equipment and supplies for the treatment of insulin-dependent diabetes, insulin-using diabetes, gestational diabetes, and non-insulin-using diabetes if prescribed by a healthcare professional legally authorized to prescribe such items.

• Pump infusion sets and supplies, outpatient self-management training and education, and nutritional therapy are covered under the Plan’s medical benefits.
• Insulin, needles, and syringes as well as testing supplies (test strips, lancets, lancet devices, blood glucose monitors, continuous glucose monitors and control solution) are covered under the Plan’s pharmacy benefits.
• Diabetes testing supplies will be limited to LifeScan products, except in the case of members using an insulin pump associated with a specific, non-LifeScan meter.

For members who may not be using a LifeScan meter currently, there are two ways to obtain a free LifeScan meter:

1. Order online at www.OneTouch.orderpoints.com and input the Sentara Health Plans order code 741OPT016;
2. Call the toll-free number: 855-776-4464 and provide the order code 741OPT016

30% coinsurance of the Plan allowance

External insulin pumps

Nothing 

Not covered:

• Motorized wheelchairs or scooters
• Exercise equipment
• Air conditioners, purifiers, humidifiers, and dehumidifiers
• Whirlpool baths
• Convenience items, including but not limited to hypoallergenic bed linens, water purification devices, and adaptive feeding devices
• Telephones
• Changes made to vehicles, residences, or places of business including, but not limited to, handrails, ramps, elevators, and stair glides
• Repair or replacement of equipment damaged through neglect or loss
• More than one item of equipment for the same purpose
• Disposable medical supplies, including but not limited to medical dressings, disposable diapers
• Durable medical equipment primarily for comfort and well being of the member
• Care and services from non-plan providers unless precertified by the Plan prior to receiving the service

• Home healthcare ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.V.N.), or home health aide
• Services include oxygen therapy, intravenous therapy and medications
• Part-time or intermittent nursing care
• Part-time or intermittent home health aide services
• Surgical dressings and medical appliances

$25 copayment

• Physical, occupational, or speech therapy

20% coinsurance of our Plan allowance

Not covered:

• Nursing care requested by, or for the convenience of, the patient or the patient’s family
• Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative
• Services primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medication
• Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service

No benefit

All charges

No benefit

All charges

Coverage is provided for:

• Diabetes self management

Note: Members should call 1-800-SENTARA for information on classes

Nothing 

• Counseling and education for birth control options

Nothing 

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

Nothing 

• Multicomponent, family centered programs focused on childhood obesity that are part of intensive behavioral interventions (behavior change counseling for healthy diet and physical activity) as recommended under the U.S. Preventive Services Task Force (USPSTF) A and B recommendations.

Cost-sharing dependent on place of service

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery )
• Surgical treatment of severe obesity (bariatric surgery) -- a condition in which an individual weighs 100 pounds or 100% over their normal weight according to current underwriting standards; eligible members must be age 18 or over.
• Insertion of internal prosthetic devices. See 5(a) – Orthopedic and prosthetic devices for device coverage information
• Voluntary sterilization (e.g., vasectomy)
• Treatment of burns

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

20% coinsurance of our Plan allowance

Not covered:

• Reversal of voluntary sterilization
• Routine treatment of conditions of the foot; see Foot care
• Surgery primarily for cosmetic purposes
• Any surgical services, other than emergent, which have not been pre-authorized by the Plan.
• Any surgical services determined not medically necessary by the Plan.
• Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service

• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
  • the condition produced a major effect on the member’s appearance and 
  • the condition can reasonably be expected to be corrected by such surgery
• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: protruding ear deformities; cleft lip; cleft palate; birth marks; and webbed fingers and toes.
• All stages of breast reconstruction surgery following a mastectomy, such as:
  • surgery to produce a symmetrical appearance of breasts;
  • treatment of any physical complications, such as lymphedemas;
  • breast prostheses and surgical bras and replacements (see Prosthetic devices) 

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

20% coinsurance of our Plan allowance

Gender Affirming Surgery

The following genital surgeries may be considered for male to female: 

• Orchiectomy - removal of testicles
• Penectomy - removal of penis
• Vaginoplasty - creation of vagina
• Clitoroplasty - creation of clitoris
• Labiaplasty - creation of labia
• Mammaplasty - breast augmentation
• Prostatectomy -removal of prostate
• Urethroplasty - creation of urethra

The following genital surgeries may be considered for female to male:

• Breast reconstruction (e.g., mastectomy) - removal of breast
• Nipple reconstruction (only if a mastectomy has been done)
• Hysterectomy - removal of uterus
• Salpingo-oophorectomy - removal of fallopian tubes and ovaries
• Vaginectomy - removal of vagina
• Vulvectomy - removal of vulva
• Metoidioplasty - creation of micro-penis, using clitoris
• Phalloplasty - creation of penis, with or without urethra
• Urethroplasty - creation of urethra within the penis
• Scrotoplasty - creation of scrotum
• Testicular prostheses - implantation of artificial testes

20% coinsurance of our Plan allowance

Not covered:

• Cosmetic surgery 
• Any surgical services, other than emergent, which have not been precertified by the Plan
• Any surgical services determined not medically necessary by the Plan
• Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service

Oral surgical procedures, limited to:

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

20% coinsurance of our Plan allowance

Not covered:

• Oral implants and transplants
• Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)
• Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service.

These solid organ transplants are subject to medical necessity and experimental/investigational review by the Plan. See Other services under You need prior Plan approval for certain services on page 19.

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

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
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Acute myeloid leukemia
  • Advanced Myeloproliferative Disorders (MPDs)
  • 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, PNH, 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
• 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
  • Epithelial Ovarian Cancer
  • Ewing’s sarcoma
  • Multiple myeloma
  • Medulloblastoma
  • 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
  • Advanced Hodgkin’s lymphoma with recurrence (relapsed)
  • Advanced non-Hodgkin’s lymphoma with recurrence (relapsed)
  • Acute myeloid leukemia
  • Advanced Myeloproliferative Disorders (MPDs)
  • 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
  • Chronic inflammatory demyelination polyneuropathy (CIDP)
  • 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 myelogenous leukemia
  • Colon cancer
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Myeloproliferative disorders (MSDs)
  • Myelodysplasia/Myelodysplastic Syndromes
  • 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
  • Aggressive non-Hodgkin lymphomas
  • Breast Cancer
  • Childhood rhabdomyosarcoma
  • Chronic myelogenous leukemia
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Epithelial Ovarian Cancer
  • Mantle Cell (Non-Hodgkin lymphoma)

National Transplant Program (NTP)

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

20% coinsurance of our Plan allowance

Not covered:

• Donor screening tests and donor search expenses, except as shown above
• Implants of artificial organs
• Transplants not listed as covered 
• Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service.

Professional services provided in –

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

20% coinsurance of our Plan allowance

Room and board, such as

• Ward, semiprivate, or intensive care accommodations
• General nursing care
• Meals and special diets

20% coinsurance of our Plan allowance

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and X-rays
• Administration of blood and blood products
• Blood or blood plasma, if not donated or replaced
• Presurgical testing
• 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
• Hospitalization and anesthesia for dental procedures as determined medically necessary by a Plan physician for members under age five, severely disabled or with a medical condition requiring hospitalization for dental procedures.

20% coinsurance of our Plan allowance

Not covered:

• Custodial care
• Non-covered facilities, such as nursing homes, schools
• Personal comfort items, such as telephone, television, barber services, guest meals and beds
• Private nursing care
• The cost of securing the services of blood donors
• Professional dental services
• Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service

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

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

20% coinsurance of our Plan allowance

Not covered:

• Blood and blood derivatives not replaced by the member
• Professional dental services and procedures
• Care and services from non-Plan providers unless precertification by the Plan prior to receiving the service

Extended care benefit/Skilled nursing facility :

The Plan provides a comprehensive range of benefits up to 100 days per calendar year when full time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan. All necessary services are covered including:

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

20% coinsurance of our Plan allowance

Not covered:

• Custodial care
• Rest cures
• Domiciliary or convalescent care
• Personal comfort items such as telephone, and television
• Blood and blood derivatives not replaced by the member
• Care and services from non-Plan providers unless precertification by the Plan prior to receiving services

A coordinated program of home and inpatient care under the direction of a Plan doctor for the patient who is in the terminal stages of illness with a life expectancy of six months or less that includes:

• Palliative Care
• Supportive physical, psychological, and psychosocial services

Note: Palliative care is treatment to control pain, relieve other symptoms and focus on the special needs of the patient.

Nothing.

20% coinsurance of our Plan allowance

Not covered:

• Independent nursing
• Homemaker services   
• Care and services from non-Plan providers unless precertified by the Plan prior to receiving the service

20% coinsurance of our Plan allowance

Emergency care at a doctor’s office

$25 copayment per primary care provider office visit 

$55 copayment per specialist office visit 

Emergency care at an urgent care center

$55 copayment per visit 

Emergency care as an outpatient or inpatient at a hospital, including doctors services

20% coinsurance of our Plan allowance

Emergency care at a doctor’s office

$25 copayment per primary care provider office visit

$55 copayment per specialist office visit

Emergency care at an urgent care center

$55 copayment per visit

Emergency care as an outpatient or inpatient at a hospital, including doctors services

20% coinsurance of our Plan allowance

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

Professional ambulance service when medically appropriate

Note: See Section5(c) for non-emergency service.

20% coinsurance of our Plan allowance

When part of a treatment plan we approve, we cover professional services by licensed professional mental health and substance misuse 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

$15 copayment per office visit copay 

30% coinsurance of our Plan allowance

• 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
• MRI, CT Scans and PET Scans

30% coinsurance of our Plan allowance

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

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

30% coinsurance of our Plan allowance per admission

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

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

30% coinsurance of our Plan allowance

• Care and services from non-Plan providers unless precertified by the Plan prior to receiving the services.

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

Drugs and medications (including those administered during a non-covered admission or in a non-covered facility) that by Federal law of the United States require a physician's prescription for their purchase, except those listed as Not covered.

• Rescue and maintenance inhalers
• Insulin
• Drugs for sexual dysfunction (limited to four pills per month)
• Drugs to treat gender dysphoria 
• Intravenous fluids and medication for home use
• Infertility medications to increase production and release of as many eggs as possible may be covered with a three-cycle annual limit. Common infertility drugs used are:
  • Clomiphene citrate
  • hCG (human Chorionic Gonadotropin)
  • FSH (follicle-stimulating hormone)
  • Menotropins

Note: IVF drugs and infertility drugs do not count toward your Deductible or Maximum Out-of-Pocket Amount.

Retail Pharmacy:

$10 copayment per Tier 1 Drug

50% coinsurance per Tier 2 Drug

50% coinsurance per Tier 3 Drug

Mail Order (90-day supply of Maintenance Drugs):

$20 copayment per Tier 1 Drug

50% coinsurance per Tier 2 Drug

50% coinsurance per Tier 3 Drug

Specialty Drugs are only available through Proprium Pharmacy (limited to a 31 day supply):

50% coinsurance per Tier 4 Specialty Drug

Diabetic supplies limited to:

• Disposable needles and syringes for the administration of covered medications
• Continuous Glucose Monitor (CGM) 

Applicable copayment or coinsurance

• Test strips, lancet devices and lancets
• Blood glucose monitors and control solution

Nothing

• Contraceptive drugs and devices listed in the ACA/HRSA

Note: If you need assistance requesting a medical exception for a non-formulary contraceptive, please contact Sentara Health Plans at 1-800-229-5522.  If you have concerns about our Plan’s compliance with the requirements for coverage of oral contraception, please contact contraception@opm.gov, or refer to OPM’s web page about contraception.

Note: Injectable contraceptive drugs are covered under Family Planning Section 5(a).

• Tobacco eCessation medications

Note:  The above over-the-counter drugs and devices approved by the FDA require a written prescription by an approved plan provider.  Some restrictions apply.

Nothing 

Preventive care medications to promote better health as recommended by ACA.

The following are covered:

• Aspirin (81 mg) for men age 45-79 and women age 55-79 and women of childbearing age
• Folic acid supplements for women of childbearing age 400 & 800 mcg
• Liquid iron supplements for children age 0-2 years
• Vitamin D supplements (prescription strength) (400 & 1000 units) for members 65 or older
• Bowel Evacuant drugs
• Tamoxifen and Raloxefin for women
• Generic and over-the-counter tobacco cessation medications
• Fluoride tablets, solution (not toothpaste, rinses) for children age 0-7

Note: Preventive Medications with a USPSTF recommendation of A or B are covered without cost-share when prescribed by a healthcare 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/browserecommendations

Nothing 

Not covered:

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies
• Nonprescription medications
• Vitamins, nutrients and food supplements even if a physician prescribes or administers them (except Vitamin D, as stated above)
• Over-the-counter medications, except as noted above
• Appetite suppressants or other weight management medications
• Medical supplies such as dressings and antiseptics
• Immunization agents, biological sera, blood or blood products

All charges

We cover restorative services and supplies necessary to promptly repair (but not replace) sound natural teeth.  The need for these services must result from an accidental injury.

20% coinsurance of our Plan allowance

We have no other dental benefits.

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).

For any of your health concerns, 24 hours a day, 7 days a week, you may call and talk with a registered nurse who will discuss treatment options and answer your health questions. When you call the Nurse Triage Program have your Plan ID card handy, and describe your medical situation in as much detail as possible. Please remember that the Nurse Triage Program professional cannot diagnose medical conditions or write prescriptions. You can call the 24 Hours Nurse Triage Program at 757-552-7250 or 800-394-2237.

TDD number: 757-552-7120 or 800-225-7784

A Plan Care Manager will assist with a treatment plan prescribed by your OB/GYN physician.

Through a partnership with WebMD, we offer our members flexible programs, expert guidance, and inspiration to take charge of their own health—whether they are continuing healthy behaviors, or making a change to improve their health. It all begins when the member completes a Personal Health Assessment—and creates the foundation for their Health Record and coaching program. Our health-coaching partner, WebMD, offers a comprehensive online activities tool, known as the Digital Health Assistant (DHA). The DHA delivers a personalized, interactive, and motivational experience to help members take action and sustain healthy behaviors in a fun way.

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 757-552-7550 or 800-206-1060, or at our Web site at www.sentarahealthplans.com/federal.

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

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

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

Submit your claims to:       

Claims
P.O. Box 5028
Troy, MI 48007-5028

For Vision Service Plan non-Plan provider or out-of-network provider claims, please send your health plan name, your name, member ID number, current address, telephone number and your itemized statement. Claims must be submitted within six months of the time services are received.

Submit your claims to:     

Vision Service Plan
Attn: Claims Services
PO Box 385018
Birmingham, AL 35238-5018

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

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

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

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

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

If you live in a county where at least 10% of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that non-English language. You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as telephone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language. The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language. Any notice of an adverse benefit determination or correspondence from us confirming an adverse benefit determination will include information sufficient to identify the claim involved (including the date of service, the healthcare provider, and the claim amount, if applicable), and a statement describing the availability, upon request, of the diagnosis and procedure codes.

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

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

b) Send your request to us at: Sentara Health Appeals Department, PO Box 66189, Virginia Beach, VA 23466; 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 e-mail address (optional for member), if you would like to receive our decision via email.  Please note that by giving us your email, we may be able to provide our decision more quickly.

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

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

a)  Pay the claim or  

b)  Write to you and maintain our denial or.

c)  Ask you or your provider for more information

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

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

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

You must write to OPM within:

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

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, FEHB 2, 1900 E Street, NW, Washington, DC 20415-3620.

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 or notify you of the status of OPM’s review within 60 days.  There are no other administrative appeals.

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

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

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

Note: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call us at 757-552-7550 or 800-206-1060.  We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal.  You may call OPM’s FEHB 2 at 202-606-3818 between 8 a.m. and 5 p.m. Eastern Time.

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

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

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

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

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

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

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of these programs, eliminating your FEHB premium.  (OPM does not contribute to any applicable plan premiums.)  For information on suspending your FEHB enrollment, contact your retirement 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.

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

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

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

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

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

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

Some FEHB plans already cover some dental and vision services.  When you are covered by more than one vision/dental plan, coverage provided under your FEHB plan remains as your primary coverage.  FEDVIP coverage pays secondary to that coverage.  When you enroll in a dental and/or vision plan on 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. Some things are not covered under Original Medicare, such as prescription drugs (but coverage through private prescription drug plans will be available starting in 2006).

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

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

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

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

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. You will not need to do anything. To find out if you need to do something to file your claim, call us at 757-552-7550 or 800-206-1060 or see our website at www.sentarahealthplans.com/federal.

We waive some costs if the Original Medicare Plan is your primary payor – We will waive some out-of-pocket costs as follows:

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

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

Benefit Description: Primary Care Provider
Medical Cost Without Medicare: $25 Copayment
Medical Cost with Medicare Part A and B: After Part A deductible, 20% coinsurance of Medicare allowed amount

Benefit Description: Specialist
Medical Cost Without Medicare: $55 Copayment
Medical Cost with Medicare Part A and B: After Part A deductible, 20% coinsurance of Medicare allowed amount

Benefit Description: Inpatient Hospital
Medical Cost Without Medicare: 20% Coinsurance of our Plan allowance
Medical Cost with Medicare Part A and B: $1,260 deductible for each benefit period, Days 1-60: $0 coinsurance for each benefit period, Days 61-90: $315 coinsurance per day of each benefit period, Days 91 and beyond: $630 coinsurance per each "lifetime reserve day" after day 90 for each benefit period (up to 60 days over your lifetime)

Benefit Description: Outpatient Hospital
Medical Cost Without Medicare: 20% Coinsurance of our Plan allowance
Medical Cost with Medicare Part A and B: After Part A deductible, 20% coinsurance of Medicare allowed amount

Benefit Description: Rx
Medical Cost Without Medicare: Tier 1 - $10, Tier 2 - 50% Coinsurance, Tier 3 – 50% Coinsurance, Tier 4  - Specialty (31 day supply) – 50% Coinsurance
Medical Cost with Medicare Part A and B: Part D benefit varies by plan

Benefit Description: Rx – Mail Order (90 day supply)
Medical Cost Without Medicare: 2x retail copay (No mail order for Tier 4 drugs)
Medical Cost with Medicare Part A and B: Part D benefit varies by plan

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 (800-633-4227) (TTY 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 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.

If you are enrolled in Medicare, and are not enrolled in a Medicare Advantage Plan (Part C), you have the opportunity to enroll in the Medicare Prescription Drug Plan (PDP) Employer Group Waiver Plan (EGWP). The PDP EGWP is a prescription drug benefit for FEHB covered annuitants and their FEHB covered family members who are eligible for Medicare. This allows you to receive benefits that will never be less than your coverage that is available to members with only FEHB but more often you will receive benefits that are better than members with only FEHB.

In the case of those with higher incomes you may have a separate premium payment for your PDP EGWP benefit. Please refer to the Part D-IRMAA section of the Medicare website: https://www.medicare.gov/drug-coverage-part-d/costs-for-medicare-drug-coverage/monthly-premium-for-drug-plans to see if you would be subject to an additional premium.

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

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

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

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

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

• Medicare was the primary payor before eligibility due to ESRD

• Medicare based on age and disability

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

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

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

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

The maximum amount that an insured person will have to pay for covered expenses under the plan, usually within the plan effective dates.

• The High Option catastrophic limit is $5,500 for Self Only, $11,000 for Self Plus One or $11,000 for Self and Family enrollment.

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 are generally covered by the clinical trials.  This plan does not cover these costs.

Coinsurance is the percentage of our allowance that you must pay for your care. 
Example: In our Plan, you pay 20% of our allowance for durable medical equipment

A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services.  This plan does not have a deductible.

A drug, device, or biological product is experimental or investigational if the drug, device, or biological product cannot be lawfully marketed without approval of the U.S. Food and Drug Administration (FDA); and approval for marketing has not been given at the time it is furnished. Note: Approval means all forms of acceptance by the FDA.

A medical treatment or procedure, or a drug, device, or biological product, is experimental or investigational if:

1. Reliable evidence shows that it is the subject of ongoing phase I, II, or III clinical trials or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or
2. Reliable evidence shows that the consensus of opinion among experts regarding the drug, device, or biological product or medical treatment or procedure, is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis.

Reliable evidence shall mean only:

• Published reports and articles in the authoritative medical and scientific literature;
• The written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device, or biological product or medical treatment or procedure; or

• The written informed consent used by the treating facility or by another facility studying substantially the same drug, device, or biological product or medical treatment or procedure.

A plan or contract that provides coverage for health care services to eligible employees and their dependents.

Includes coverage for health care services and devices that help a person keep, learn, or improve skills and functioning for daily living.

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

Services, treatment, or supplies provided by a hospital, skilled nursing facility, physician, or other provider required to identify or treat your illness or injury and that as determined by your primary care physician and the Plan are:

• Consistent with the symptoms, diagnosis and treatment of your condition, disease, injury, or ailment;
• In accordance with recognized standards of care for your condition
• Appropriate standards of good medical practice
• Not solely for your convenience, or the convenience of your primary care physician, Plan provider, hospital or other provider;
• The most appropriate supply or level of service, which can be safely provided to you. As an inpatient this means that your medical symptoms or condition requires that the diagnosis, treatment or service cannot be safely provided to you as an outpatient.

Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in different ways. We determine our allowance as follows: We use a fee schedule which means our Plan providers accept a negotiated fee from us and you will only be responsible for your copayments or coinsurance.

You should also see Important Notice About Surprise Billing – Know Your Rights in Section 4 that describes your protections against surprise billing under the No Surprises Act.

Includes coverage for therapies to restore and in some cases, maintain capabilities lost due to disease, illness, injury, or in the case of speech therapy, loss additionally due to congenital anomaly or prior medical treatment.

An unexpected bill you receive for:

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

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

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

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

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

If you believe your claim qualifies as an urgent care claim, please contact our Customer Service Department at 757-552-7550 or 800-206-1060.  You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

Us and We refer to Sentara Health Plans.

This Plan does not have a deductible.

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Office visit copayment:  $25 primary care; $55 specialist

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20% coinsurance of Plan allowance

46

20% coinsurance of Plan allowance

$55 copayment per Urgent Care Center visit

50

20% coinsurance of Plan allowance

50

Regular cost-sharing

52

Retail copayment/coinsurance per 31-day supply:

• $10 copayment per Tier 1 Drug
• 50% coinsurance of plan allowance per Tier 2 Drug
• 50% coinsurance of plan allowance per Tier 3 Drug
• 50% coinsurance of plan allowance per Specialty Drug - Specialty Drugs must be obtained through Proprium Pharmacy

55

Mail Order copayment/coinsurance for 90-day supply of Maintenance Drugs:

• $20 copayment per Tier 1 Drug
• 50% coinsurance of plan allowance per Tier 2 Drug
• 50% coinsurance of plan allowance per Tier 3 Drug

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No benefit

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Covered at 100% per eyeglass exam once every 12 months

35

Nothing

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$5,500 per person regardless of enrollment tier and will not exceed more than $11,000 combined per Self Plus One or $11,000 combined per Self Plus Family.

Some costs do not count toward this protection.

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