We will not refuse to cover the treatment of a condition you had before you enrolled in this Plan solely because you had the condition before you enrolled.

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 https://health-benefits.opm.gov/PSHB/  for enrollment information as well as:

• Information on the PSHB Program and plans available to you
• A health plan comparison tool

Note: Contact the USPS for information on how to enroll in a PSHB Program Plan through the PSHB System.

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 PSHB 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. You will be responsible for making changes to your enrollment status through the PSHB System.  In some cases, your employing or retirement office may need to submit documentation. For information on your premium deductions, you must also contact your employing or retirement office.

Once enrolled in your PSHB 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. You enroll in a PSHB Program Plan and make enrollment changes in the PSHB System located at www.health-benefits.opm.gov/pshb. For assistance with the PSHB System, call the PSHBP Helpline at (844) 451-1261. 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 request. 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 PSHB enrollment. Use the PSHB system  if you want to change from Self Only to Self Plus One or Self and Family, and to add or remove a family member. 

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits.  Please, report changes in family member status, including your marriage, divorce, annulment, or when your child reaches age 26 through the PSHB System. We will send written notice to you 60 days before we proactively disenroll your child on midnight of their 26^th 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 PSHB plan, you or they cannot be enrolled in or covered as a family member by another enrollee in another PSHB or 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 PSHB Program, change your enrollment, or cancel coverage using the PSHB System.  For a complete list of QLEs, visit the PSHB website at
https://health-benefits.opm.gov/PSHB/.  If you need assistance, please contact your employing agency, personnel/payroll office, or retirement office.

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

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

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

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

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

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

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

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

OPM implements the Federal Employees Health Benefits Children’s Equity Act of 2000.  This law mandates that you be enrolled for Self Plus One or Self and Family coverage in the PSHB 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 PSHB 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 PSHB Program, you cannot cancel your enrollment, change to Self Only, or change to a plan that does not serve the area in which your children live, unless you provide documentation that you have other coverage for the children.   

If the court/administrative order is still in effect when you retire, and you have at least one child still eligible for PSHB coverage, you must continue your PSHB 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.

For annuitants who are required to be enrolled in Medicare Part B as a condition to continue PSHB coverage in retirement: If you enroll in Medicare Part B and continue PSHB coverage in retirement, the child equity law applies to you and you cannot cancel your coverage, change to Self Only, or change to a plan that does not serve the area in which your child(ren) live as long as the court/administrative order is in effect. You cannot be compelled to enroll or remain enrolled in Medicare Part B to maintain your PSHB enrollment as a condition to satisfy a court/administrative order. However, if you do not enroll (or remain enrolled) in Medicare Part B as required to continue your PSHB coverage in retirement (notwithstanding an existing court/administrative order), you will not be able to continue your PSHB coverage in retirement.

The benefits in this brochure are effective January 1.  If you joined this Plan during Open Season, your coverage and premiums begins on  January 1.  If you joined at any other time during the year, your employing or retirement office will tell you the effective date of coverage.

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

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

Our PDP EGWP is only available to Postal Service annuitants who are Medicare Part D-eligible and their covered Medicare Part D-eligible family members. Our PDP EGWP is not an open market Medicare Part D Plan.  If you are an active Postal Service employee, or covered family member, and become eligible to enroll in Medicare Part D, you are not eligible to enroll in our PDP EGWP.  Please, contact CMS for assistance at 800-MEDICARE (800-633-4227). 

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 eligible for coverage under spouse equity, you are only eligible to enroll in the FEHB Program. If you are not eligible for coverage under spouse equity and you are otherwise eligible for Temporary Continuation of Coverage (TCC), then you could enroll in TCC under the PSHB Program.

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 enter the date of the divorce or annulment and remove your ex-spouse in the PSHB System. We may ask for a copy of the divorce decree as proof.  If you need to change your enrollment type, you must use the PSHB System. 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  coverage under the spouse equity law or Temporary Continuation of Coverage (TCC). Former spouses eligible for coverage under the spouse equity law are not eligible to enroll in the PSHB Program. However, former spouses eligible for coverage under the spouse equity law may enroll in the FEHB Program. (Former Spouses seeking but not yet adjudicated as eligible for Spouse Equity may be entitled to TCC under a PSHB plan in the interim).

Former spouses not meeting the spouse equity requirements may be eligible for TCC under the PSHB Program provided you otherwise meet the eligibility requirements for 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 https://www.opm.gov/healthcare-insurance/life-events/memy-family/im-separated-or-im-getting-divorced/#url=Health. We may request that you verify the eligibility of any or all family members listed as covered under the enrollee’s PSHB enrollment.

If you leave Federal service, 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 PSHB enrollment after you retire, if you lose your Federal job, or if you are a covered child and you turn 26.

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

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

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for 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 PSHB Program coverage.

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

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

If you leave Federal 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 PSHB 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  800-556-9765 or visit our website at www.hap.org/pshb.

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.

When a Postal Service annuitant who is Medicare Part D-eligible or their covered Medicare-eligible family member opts out of or disenrolls from our PDP EGWP, they will not have our prescription drug coverage under this plan. If you do not maintain creditable coverage, re-enrollment in our PDP EGWP may be subject to a late enrollment penalty.  Contact us for additional information at  800.236.4782.

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 PSHB System enrollment confirmation.  Note:  If you are enrolled in our Medicare Part D PDP EGWP, you may receive a second ID card for your prescription drug benefits. 

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 313-664-8757 or 800-556-9765 or write to us at HAP, 1414 E. Maple Rd. Troy MI 48083.. If you know your HAP ID Number, you may also request replacement cards through our website at www.hap.org. ID cards may also be viewed at any time on the HAP App mobile app (available for iTunes and Android).

You can receive coverage under this plan on your effective enrollment date. Your effective enrollment date is the first day of your first pay period that starts on or after January 1st. For a few days at the beginning of the year, you may be under your prior plan. Please check with your employing office if you have questions about your effective enrollment date or if you are a new employee.

HMO members need to choose a PCP. HAP’s HMO network includes thousands of
doctors and leading hospitals. Your PCP will provide your preventive care, keep your
medical history updated and help you choose a specialist if you need one.

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

Benefits are provided under this Plan for the services of covered providers, in accordance with Section 2706(a) of the Public Health Service Act. Coverage of practitioners is not determined by your state’s designation as a medically underserved area. We list Plan providers in the provider directory, which we update periodically. For the most up-to-date list, visit our website at www.hap.org/providers.

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 800-556-9765 for assistance.

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

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

If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below. If your claim is in reference to a contraceptive, call 800-556-9765.

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.

It depends on the type of care you need. First, you and each family member must choose a primary care provider. Each covered member on your plan may choose their own primary care provider.. This decision is important since your primary care provider. provides or arranges for most of your health care. See "Primary Care" section below for information about how to choose a primary care provider.

HMO members need to choose a PCP. Our HMO network includes thousands of doctors and leading hospitals. To find doctors within your HMO plan, visit hap.org/hmo doctors. You can also call a PCP selection specialist at (888) 742-2727 With this plan, your care is coordinated through your primary care provider. Your PCP will provide your preventive care, keep your medical history updated and help you choose a specialist if you need one. When you need to see a specialist for an initial consultation, you don’t need to get a referral from HAP.

No matter what network and doctor you choose, you're going to get the care you need.

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

You may change your primary care provider. at any time for any reason. If you would like to change your primary care provider., please call us. If your primary care provider. leaves the plan, we will contact you and help you select a new one. Simply call our primary care provider. Select line at 888-PIC-A-PCP or 888-742-2727. You may also select a primary care provider. online. Log in at www.hap.org and select the tab: Find a Doctor/Facility

Your primary care provider. (PCP) will refer you to a specialist for needed care. HAP doesn’t require you to get a referral to see a specialist in your network for an initial consultation. However, the specialist you visit may require a referral from your PCP. The schedules for certain specialists get filled months in advance. They may only accept patients whose PCP believes the patient needs specialty care. You can get behavioral health services without a referral from your PCP, by calling 800-444-5755.

Here are some other things you should know about specialty care: Chronic/serious ongoing conditions:

• If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your PCP will provide a recommendation for you to see a specialist for care, HAP does not require a referral.
• If you are seeing a specialist when you enroll in HAP’s plan, and your current specialist does not participate with HAP, you must receive treatment from a specialist who does. Generally, HAP will not pay for you to see a specialist who does not participate with our Plan.

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

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 313-664-8757 or 800-556-9765. If you are new to the PSHB 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 PSHB plan to us, your former plan will pay for the hospital stay until:

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

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

Since your primary care provider arranges most referrals to specialists and inpatient hospitalization, the pre-service claim approval process only applies to care shown under Other services. You must get prior approval for certain services. Failure to do so will result in cost share. 

Prior authorization/precertification is a review process that ensures you meet the criteria for elective or emergency admissions before going into the hospital. All elective admissions need prior authorization/precertification before you receive inpatient services such as hospital, skilled nursing facility, hospice and behavioral health. If you are admitted to a hospital that isn’t affiliated with us, we may call the doctor treating you to check your status and your care plan. When it is safe, you may be transferred to an affiliated hospital. If you refuse to be transferred, your care at the non-affiliated hospital will not be covered or may be covered at a reduced benefit level. If services such as inpatient care and treatment are needed, you can notify us by calling the number on the back of your ID card.

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

• Diagnostic tests such as a MRI or CT Scan
• Durable medical equipment
• Growth hormone therapy (GHT)
• Home care services
• Inpatient care
• Non-emergency ambulance services
• Select outpatient procedures
• Transplants
• Specialty drugs
• Genetic Testing

Physicians may contact us by phone, fax or electronically to submit new requests or to seek a renewal or extension of an existing referral.

You do not need a referral from your doctor to obtain behavioral health care (mental health and substance abuse services). You may directly access services by contacting Coordinated Behavioral Health Management at 800-444-5755.

First, your physician, your hospital or your representative, must call us at 800-422-4641 before admission or services requiring prior authorization are rendered.

Next, provide the following information:

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

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

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

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

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

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

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 800-422-4641. You may also call OPM’s Postal Service Insurance Operations (PSIO)  at 202-936-0002 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We will cooperate with OPM so they can quickly review your claim on appeal. In addition, if you did not indicate that your claim was a claim for urgent care, call us at 800-422-4641. 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. Any reduction or termination of our pre-approved course of treatment before the end of the approved period of time or number of treatments is an appealable decision. This does not include reduction or termination due to benefit changes or if your enrollment ends. If we believe a reduction or termination is warranted, we will allow you sufficient time to appeal and obtain a decision from us before the reduction or termination takes effect.

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

If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the physician, or the hospital must phone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital. If you are admitted to a hospital that isn’t affiliated with us, we may call the doctor treating you to check your status and your care plan. When it is safe, you may be transferred to an affiliated hospital. If you refuse to be transferred, your care at the non- affiliated hospital will not be covered or may be covered at a reduced benefit level.

Referrals are not required for OB/GYN services. Complete maternity (obstetrical) care is covered, such as:

• Prenatal & Postpartum care
• Screening for gestational diabetes for pregnant women between 24-28 weeks gestation or first prenatal visit for women at a high risk
• Delivery
• Postnatal care
• Screening and counseling for prenatal and postpartum depression

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.

See page 30 for more information on maternity care. See page 29 for information on women's preventive care.

If you request an extension of an ongoing course of treatment at least 24 hours prior to the end 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.

Failure to follow the precertification rules for non-network facilities could result in denial of coverage for services and the member will be responsible for payment to non-network providers.

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

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

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

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

If we do not receive the information within 60 days, we will decide within 30 days of the date 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.

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

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

Note: If you are enrolled in our Medicare PDP EGWP and do not agree with our benefit coverage decision you have the right to appeal.  See Section. 8(a) for information about the PDP EGWP appeal process.

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

Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible, 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 certain services.

Example: When you see your primary care provider, you pay a copayment of $10 per office visit, and when you go in the hospital, you pay $100 per admission.

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

• The High Option has no deductible. The calendar year deductible is $350 per person under the Standard Option. The deductible is considered satisfied and benefits are payable for you when your covered expenses applied to the calendar year deductible for your enrollment reach $350.00. Under a Self Plus One, the deductible is considered satisfied and benefits are payable for you and one other eligible family member when the combined covered expenses applied to the calendar year deductible for your enrollment reach $700.00. Under a Self and Family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $700.00.

Note: If you change PSHB plans during Open Season, the effective date of your new PSHB plan is January 1 of the next year, and a new deductible starts on January 1.  If you change plans at another time during the year, you must begin a new deductible under your new plan.

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

Coinsurance is the percentage of our allowance (0% for High Option; 10% for Standard Option) that you must pay for your care.  Coinsurance does not begin until you have met your calendar year deductible.

Example: In our Plan, you pay 50% 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.

High Option Plan
After your out-of-pocket expenses, including any applicable deductibles, copayments and coinsurance total $6,350 for Self Only, or $12,700 for a Self Plus One or Self and Family enrollment in any calendar year, you do not have to pay any more for covered services. The maximum annual limitation on cost sharing listed under Self Only of $6,350 applies to each individual, regardless of whether the individual is enrolled in Self Only, Self Plus One, or Self and Family.

Standard Option Plan
After your out-of-pocket expenses, including any applicable deductibles, copayments and coinsurance total $6,350 for Self Only, or $12,700 for a Self Plus One or Self and Family enrollment in any calendar year, you do not have to pay any more for covered services. The maximum annual limitation on cost sharing listed under Self Only of $6,350 applies to each individual, regardless of whether the individual is enrolled in Self Only, Self Plus One, or Self and Family.

Example Scenario: Your High Option plan has a $6,350 Self Only maximum out-of-pocket limit and a $12,700 Self Plus One or Self and Family maximum out-of-pocket limit. If you or one of your eligible family members has out-of-pocket qualified medical expenses of $6,350 or more for the calendar year, any remaining qualified medical expenses for that individual will be covered fully by your health plan. With a Self and Family enrollment out-of-pocket maximum of $12,700, a second family member, or an aggregate of other eligible family members, will continue to accrue out-of-pocket qualified medical expenses up to a maximum of $6,350 for the calendar year before their qualified medical expenses will begin to be covered in full.

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

• No copay for High Option plan, 10% after deductible for Standard Option Plan for infertility treatment.
• Expenses for services and supplies that exceed the stated maximum dollar or day limit.

For members enrolled in our Plan's associated MA-PD or PDP EGWP, we are required to accumulate all members’ actual out-of-pocket costs for Medicare-covered drugs, services and supplies toward the PSHB catastrophic maximum(s), unless specifically excluded below.

If you are enrolled in our Medicare Prescription Drug Plan (PDP) Employer Group Waiver Plan (EGWP), the prescription drug out-of-pocket maximum is $2,000.  After this maximum is met, we pay 100% of all eligible covered prescription drug benefits.

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

If you changed to this PSHB Plan during Open Season from a plan with a catastrophic protection benefit the effective date of the change is January 1, and covered expenses that apply to this plan’s catastrophic protection benefit starts on January 1. 

Note: If you change PSHB plans during Open Season the effective date of your new PSHB plan is January 1 of the next year, and a new catastrophic protection accumulation starts on January 1. If you change plans at another time during the year, you must begin a new catastrophic protection accumulation under your new plan.

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

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

The No Surprises Act (NSA) is a federal law that provides you with protections against “surprise billing” and “balance billing” . 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 Michigan.  

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.hap.org/surprise-billing or contact the health plan at 800-556-9765.

Professional services of physicians

• In physician's office
• Office medical consultations
• Second surgical opinion

$20 per visit to your primary care provider

$40 per visit to a specialist

$20 per visit to your primary care provider

$50 per visit to a specialist

At Home

Nothing 

Nothing after deductible 

Through our contracted Telehealth services provider

PCP

Specialist 

Nothing 

$20 Copay Per Visit

$40 Copay per visit

Nothing 

$20 Copay per visit

$50 copay per visit 

Tests, such as:

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

Nothing 

10% after deductible 

Advanced Diagnostic Imaging Services, such as:

• CT Scans
• MRI
• CTA scans
• MRA
• PET scans
• Nuclear cardiology

$150

10% after deductible

 Physical Screening - One covered visit per year

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

• U.S. Preventive Services Task Force (USPSTF) A and B recommended screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer screening. For a complete list of screenings go to the U.S. Preventive Services Task Force (USPSTF) website at 
  www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
• 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
  www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations
• Individual counseling on prevention and reducing health risks
• Preventive care benefits for women such as Pap smears, gonorrhea prophylactic medication to protect newborns, annual counseling for sexually transmitted infections, contraceptive methods, and screening for interpersonal and domestic violence. For a complete list of preventive care benefits for women go to the Health and Human Services (HHS) website at
  www.hrsa.gov/womens-guidelines.
• To build your personalized list of preventive services go to https://health.gov/myhealthfinder

Nothing 

Nothing 

•  Prostate Specific Antigen (PSA) test Screening – one annually for men age 40 and older

Nothing

Nothing 

mammogram screening - Covered

Nothing 

Nothing

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

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

Nothing

Nothing 

Not covered:

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

All Charges

All Charges

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

• Intensive nutrition and behavioral weight-loss counseling therapy, in network family center programs
• Members can be referred for comprehensive intensive behavioral interventions.
• Anti-obesity medications are covered under the Pharmacy benefit. See Section 5(f) or 5(f)(a), if applicable for cost share requirements for anti-obesity medications.
• Bariatric or Metabolic surgical treatment or intervention is covered as a surgical benefit when criteria are met. See Section 5(b) for surgery requirements and cost share.

Nothing

Nothing 

Well-child visits, examinations, and other preventive services as described in the Bright Future Guidelines provided by the American Academy of Pediatrics. For a complete list of the American Academy of Pediatrics Bright Futures Guidelines go to
www.brightfutures.aap.org.

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

Nothing 

Nothing 

You can also find a complete list of U.S. Preventive Services Task Force (USPSTF) online at
www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations.

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

Nothing

Nothing

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

• Intensive nutrition and behavioral weight-loss counseling therapy, in network family center programs
• Members can be referred for comprehensive intensive behavioral interventions.
• Anti-obesity medications are covered under the Pharmacy benefit. See Section 5(t) for cost share requirements for anti-obesity medications.
• Bariatric or Metabolic surgical treatment or intervention is covered as a surgical benefit when criteria are met. See Section 5(b) for surgery requirements and cost share.

Nothing

Nothing 

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

All charges

All charges

Complete maternity (obstetrical) care, such as:

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

Nothing for routine prenatal or routine postpartum care visits.

Nothing for inpatient professional delivery services.

Nothing for routine prenatal or routine postpartum care visits.

10% after deductible for inpatient professional delivery services.

Breastfeeding and lactation support, supplies and counseling for each birth.

Note: Here are some things to keep in mind:

• You do not need to pre-certify your vaginal delivery;
• 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 cover medically necessary sonograms to determine fetal age, and size.  The gender is also identified.
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury. 
• Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).
• As part of your coverage, you have access to in-network certified nurse midwives, board-certified lactation specialists during the prenatal and post-partum period.

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

Nothing

Nothing 

Contraceptive counseling on an annual basis

Nothing

Nothing

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

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

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

Note: See additional Family Planning and Prescription drug coverage Section 5(f) or 5(f)(a) if applicable.

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

Physicians who prescribe contraceptives not listed on HAP’s formulary will submit a medical
exception request that documents the medical necessity of the non-formulary drug. Upon
submission of the medical necessity request by the physician, the drug will be covered at zero cost
share. Requests are reviewed based on urgency with a 24-hour turnaround time for urgent cases
and a 72-hours turnaround time for standard requests.

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

$20 through Primary Care

$40 per office visit

Generic drugs: $0 cost sharing

$20 through Primary Care

$50 per office visit

Generic drugs: $0 cost sharing

Not covered:

• Reversal of voluntary surgical sterilization

All charges

All Charges

Diagnosis and treatment of infertility specific to

• Artificial insemination:
  • Intravaginal insemination (IVI)
  • Intracervical insemination (ICI)
  • Intrauterine insemination (IUI)
• Fertility Drugs see section 5(f)  

Note: We cover injectable fertility drugs and oral fertility drugs under the prescription drug benefit.

See section 10 for definition of infertility

Note: Please contact HAP for complete coverage details. See section 10 for a definition of infertility 

$20 per office visit to your primary care provider

$40 per office visit to a specialist

$20 per office visit to your primary care provider

$50 per office visit to a specialist

Medically Necessary Fertility Preservation such as Iatrogenic infertility services

• Retrieval of sperm and eggs
• Cryopreservation
• Storage for preserved specimen for 1 year after a covered preservation procedure.

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

• Lab, X-ray and other diagnostic tests, as described in section 5(a)
• Surgical services as described in section 5(b)
• Outpatient hospital or ambulatory surgical center as described in Section 5(c)
• Prescription drugs as described in Section 5 (f)

$40 per office visit to a specialist

$50 per office visit to a specialist

10% after deductible for treatments

Not covered:

These exclusions apply to fertile as well as infertile individuals or couples:

• Assisted reproductive technology (ART) procedures, such as:
  • In vitro fertilization (IVF)
  • Embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)

• Services and supplies related to ART procedures
• Cost of donor sperm
• Cost of donor egg
• Any charges associated with thawing and storage of frozen sperm, eggs and embryos, unless listed as covered above for Iatrogenic infertility
• Ovum Transplants
• Infertility services when either member of the family has been voluntarily, surgically sterilized
• Services to reverse voluntary, surgically induced infertility.
• Surrogates

All charges

All Charges

• Testing and treatment

$20 per office visit to your primary care provider.

$40 per office visit to a specialist

$20 per office visit to your primary care provider.

$50 per office visit to a specialist

Allergy injections/ Allergy Serums

Nothing

10% after ded

Not covered:

• Sublingual allergy desensitization
• Provocative food testing

All charges

All Charges

• • Chemotherapy and radiation therapy

  Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on page 40.

  • Respiratory and inhalation therapy
  • Cardiac rehabilitation following qualifying event/condition is provided for up to 36 sessions
  • Dialysis – hemodialysis and peritoneal dialysis
  • Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy
  • Growth hormone therapy (GHT)
  • Chemotherapy and radiation therapy
  • Applied Behavior Analysis (ABA) - Individuals with autism spectrum disorder

  Note:  Growth hormone is covered under the prescription drug benefit.

  Note: We only cover GHT when we preauthorize the treatment.  We will ask you to submit information that establishes that the GHT is medically necessary.  Ask us to authorize GHT before you begin treatment.  We will only cover GHT services and related services and supplies that we determine are medically necessary.  See Other services under You need prior Plan approval for certain services on page 18.

  Services are covered for members according to HAP's benefit and practice policies.  Please contact HAP for details.

$20 per office visit to your primary care provider.

$40 per office visit to a specialist

No copay for treatments.

$20 per office visit to your primary care provider.

$50 per office visit to a specialist

10% after deductible for treatments.

Rehabilitative and Habilitative services: 60 visits combined with speech therapy and habilitative services per benefit period for the services of each of the following:

• Qualified physical therapists
• Occupational  therapists

Note:  We only cover therapy when a physician:

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

$40 per visit

Nothing per visit during covered inpatient admission

$25 copay per visit

Not covered:

• Long-term rehabilitative therapy
• Exercise programs

All charges

All Charges

Rehabilitative and Habilitative services: 60 visits combined with physical and occupational therapy and habilitative services per benefit period.

$40 per visit

Nothing per visit during covered inpatient admission.

$25 copay per visit

Nothing per visit during covered inpatient admission.

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

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

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

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

$20 per office visit to your primary care provider.

$40 per office visit to a specialist

$0 copay per aid for Value Level Technology - Basic digital hearing aid intended for simpler sound situations, best for people who live quieter lives

$689 copay per aid for Basic Technology Digital hearing aid that is good for one-on-one conversations, helps in listening situations with minimal background noise

$989 copay per aid for Prime Technology - Digital hearing aid that is good for moderate levels of background noise, ideal for quieter restaurants and shopping

$1,539 copay per aid for Advanced Technology Digital hearing aid that is good for high activity level, improved speech clarity, hearing aids communicate with each other (binaural processing), better sound quality than Prime or Basic and it assists with background noise

$2,039 copay per aid for Premium Technology - Digital hearing aid that delivers the best hearing and speech clarity, even in complex sound solutions, extremely high activity level. This aid has the most advanced features (noise reduction, wind noise manager)

$20 per office visit to your primary care provider.

$50 per office visit to a specialist

$0 copay per aid for Value Level Technology - Basic digital hearing aid intended for simpler sound situations, best for people who live quieter lives

$689 copay per aid for Basic Technology Digital hearing aid that is good for one-on-one conversations, helps in listening situations with minimal background noise

$989 copay per aid for Prime Technology - Digital hearing aid that is good for moderate levels of background noise, ideal for quieter restaurants and shopping

$1,539 copay per aid for Advanced Technology Digital hearing aid that is good for high activity level, improved speech clarity, hearing aids communicate with each other (binaural processing), better sound quality than Prime or Basic and it assists with background noise

$2,039 copay per aid for Premium Technology - Digital hearing aid that delivers the best hearing and speech clarity, even in complex sound solutions, extremely high activity level. This aid has the most advanced features (noise reduction, wind noise manager)

Not covered:

Hearing services that are not shown as covered

All charges

All Charges

• Eye care and vision services including routine eye exams, provided by an authorized ophthalmologist or optometrist

$0 cost share for routine annual exams

$40 per office visit to a specialist

$0 cost share for routine annual exams

$50 per office visit to a specialist

Not covered:

• Eyeglasses or contact lenses, except as shown above
• Eye exercises and orthoptics
• Radial keratotomy and other refractive surgery

All charges

All charges

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

$20 per office visit to your primary care provider.

$40 per office visit to a specialist

$20 per office visit to your primary care provider.

$50 per office visit to a specialist

Not covered:

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

All charges

All Charges

• • 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.
  • External hearing aids
  • 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.
  • Coverage for Orthopedic and corrective shoes may be available for members with diabetes in accordance with HAP’s Benefit, Referral, and Practice Policies

  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.

Plan pays 50%

Coverage provided for approved equipment

Plan pays 50% after deductible

Coverage provided for approved equipment

Not covered:

• Orthopedic and corrective shoes arch supports, foot orthotics, heel pads and heel cups
• Arch supports
• Foot orthotics
• Heel pads and heel cups
• Lumbosacral supports
• Corsets, trusses, elastic stockings, support hose, and other supportive devices

All Charges

All Charges

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

• Oxygen
• Dialysis equipment
• Hospital beds
• Wheelchairs
• Crutches
• Walkers
• Audible prescription reading devices
• Speech generating devices 
• Blood glucose monitors
• Insulin pumps

Note: You must call us at 313-664-8757 or 800-556-9765 as soon as your Plan physician prescribes this equipment. We will arrange with a healthcare provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

Plan pays 50%

Coverage provided for approved equipment

You do not pay a copayment for diabetes equipment (glucose monitors, insulin pumps).

Plan pays 50% after deductible

Coverage provided for approved equipment

You do not pay a copayment for diabetes equipment (glucose monitors, insulin pumps).

Medical Foods

The following are Covered Services when the coverage criteria in Our Benefit, Referral and Practice Policies is met

• Medical Formula and Medical Foods for infants through 12 months of age for who have been diagnosed with an inborn error of metabolism.  Medical Formula and Medical Food means a nutritional formula or food that is specifically formulated for the treatment of inborn errors of metabolism including, but not limited to amino acid or organic metabolism.

50% coinsurance

50% coinsurance

• Medical Formula and Medical Foods for those 1 year of age and older who have been diagnosed with an inborn error of metabolism.  Medical Formula and Medical Food means a nutritional formula or food that is specifically formulated for the treatment of inborn errors of metabolism including, but not limited to amino acid or organic metabolism.

Covered 100% up to a maximum benefit of $5000 per Benefit year.  Once the $5000 max is met, member pays entire cost.

Covered 100% up to a maximum benefit of $5000 per Benefit year.  Once the $5000 max is met, member pays entire cost.

Not covered:

• Foot Orthotics
• Physician Equipment
• Medical equipment needed only for comfort and convenience
• Replacement or repair of any medical equipment or prosthetic or orthopedic device due to misuse, whether intentional or unintentional
• Eyeglasses or contact lenses included fitting of contact lenses except as necessary for the first pair of corrective lenses
• Except as listed under Covered Services, all food, formula and nutritional supplements are not covered.  This includes, but is not limited to, infant formula, protein or caloric boosting supplements, vitamins, osmolytes, Ensure®, Glucerna®, and herbal preparations or supplements, even if approved by the Food and Drug Administration.

All charges

All Charges

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

Nothing

10% after deductible

Not covered:

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

All charges

All charges

• Chiropractic Manipulative Treatment of the spine and Extraspinal Chiropractic Manipulative Treatment

All Charges

$50 copay 20 visit limit – includes X-ray

No benefit

All charges

All charges

Coverage is provided for:

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

The physician must write a prescription for OTC products to be covered under the pharmacy benefit.

Other programs may be available. Contact Plan for details.

$20 per office visit to your primary care provider. may apply (if not a preventive visit)

$40 per office visit to a specialist may apply (if not a preventive visit)

Nothing for counseling for up to two quit attempts per year.

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

$20 per office visit to your primary care provider. may apply (if not a preventive visit)

$50 per office visit to a specialist may apply (if not a preventive visit)

Nothing for counseling for up to two quit attempts per year.

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

• Diabetes self management

$20 per office visit to your primary care provider.

$40 per office visit to a specialist

$20 per office visit to your primary care provider. / $50 per office visit to a specialist

10% after deductible (if billed as a group/class setting)

• Childhood obesity screening programs and treatment interventions

Nothing

Nothing

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)– eligible members must meet the following criteria: Bariatric surgery or similar endoscopic weight loss procedures are limited to one surgery/procedure per lifetime.  Bariatric surgery or similar endoscopic weight loss procedures when performed at a facility approved by Us.  All services must be Medically Necessary according to Our Benefit, Referral and Practice Policies
•  Insertion of internal prosthetic devices .  See 5(a) – Orthopedic and prosthetic devices for device coverage information
•  Treatment of burns

Nothing

10% after deductible for Outpatient surgery

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

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

Nothing for women's preventative

$20 per office visit to your primary care provider.

$40 per office visit to a specialist

Nothing for women's preventative

$30 per office visit to your primary care provider.

$50 per office visit to a specialist

Not covered:

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

All charges

All charges

• • Surgery to correct a functional defect
  • Surgery to correct a condition caused by injury or illness if:
    • the condition produced a major effect on the member’s appearance and
    • the condition can reasonably be expected to be corrected by such surgery
  • Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of congenital anomalies are: cleft lip; cleft palate; 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.

  • Gender Affirming Surgery:
  • For female to male surgery: mastectomy, hysterectomy, vaginectomy, salpingo-oophorectomy
  • For male to female surgery: penectomy, orchiectomy, Facial Feminization surgery
  • For a full list of covered procedures, please see plan documents on your HAP portal

Nothing

10% for Outpatient surgery

Not covered:

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

All charges

All charges

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.

Nothing

10% for Outpatient surgery

Not covered:

• Oral implants and transplants
• Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)

All charges

All charges

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

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

Nothing

10% after deductible 

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

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

Nothing

10% after deductible 

Blood or marrow stem cell transplants

The Plan extends coverage for the diagnoses as indicated below.

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

Nothing

10% after deductible 

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

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

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

Nothing

10% after deductible

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

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

• Allogeneic transplants for
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Beta Thalassemia Major
  • Chronic inflammatory demyelination polyneuropathy (CIDP)
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
  • Multiple sclerosis
  • Sickle Cell anemia
• Mini-transplants (non-myeloablative allogeneic, reduced intensity conditioning or RIC) for
  • Acute lymphocytic or non-lymphocytic (i.e., myelogenous) leukemia
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Breast cancer
  • Chronic lymphocytic leukemia
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Colon cancer
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Multiple myeloma
    Multiple sclerosis
  • Myelodysplasia/Myelodysplastic Syndromes
  • Myeloproliferative disorders (MDDs)
  • Non-small cell lung cancer
  • Ovarian cancer
  • Prostate cancer
  • Renal cell carcinoma
  • Sarcomas
  • Sickle cell anemia
• Autologous Transplants for
  • Advanced childhood kidney cancers
  • Advanced Ewing sarcoma
  • Advanced Hodgkin’s lymphoma
  • Advanced non-Hodgkin’s lymphoma
  • Aggressive non-Hodgkin lymphomas
  • Breast Cancer
  • Childhood rhabdomyosarcoma
  • Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/SLL)
  • Chronic myelogenous leukemia
  • Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
  • Epithelial Ovarian Cancer
  • Mantle Cell (Non-Hodgkin lymphoma)
  • Multiple sclerosis
  • Small cell lung cancer
  • Systemic lupus erythematosus
  • Systemic sclerosis

Nothing

10% after deductible 

• 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.

Nothing

10% after deductible

Not covered:

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

All charges

All charges

Professional services provided in –

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

Nothing

10% after deductible

Room and board, such as

• Ward, semiprivate, or intensive care accommodations
• General nursing care
• Meals and special diets
  
  Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and X-rays
• 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 (Note: calendar year deductible applies.)

$100 per day up to a maximum of $500 per admission copay.

10% after deductible

Not covered:

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

All charges

All charges

• 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.

$250

10% after deductible

Not covered: Blood and blood derivatives not replaced by the member

All charges

All charges

Extended care benefit:

The Plan provides a comprehensive range of benefits when full-time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor. The High Option plan pays for up to 730 days each continuous period of confinement or for successive periods separated by less than 60 days. The Standard Option plan pays for up to 100 days each continuous period of confinement or for successive periods separated by less than 60 days. Each plan's period will be reduced by two days for every inpatient hospital day prior to or during an admission to a skilled nursing facility. A new period of 100 days will begin after at least 60 days have elapsed from the last date of discharge. You pay nothing. 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.

Nothing

10% after deductible

Not covered: custodial care

All charges

All charges

Supportive and palliative care for a terminally ill member is covered in the home or hospice facility.  Services include inpatient and outpatient care, and family counseling; those services, which are provided under the direction of a Plan, doctor who certified that the patient is in the terminal stages of illness, with the life expectancy of approximately six months or less.  This benefit is limited to 210 days per member per lifetime.

Nothing

10% after deductible

Not covered: Independent nursing, homemaker services

All charges

All charges

No benefits

All charges

All charges

Local professional ambulance service when medically appropriate (Emergency transport only).

$150 copay

10% after deductible

• Emergency care at a doctor's office

$20 per office visit to your primary care provider.

$30 per office visit to your primary care provider.

• Emergency care at an urgent care center

$50 per visit to an urgent care center

$50 per visit to an urgent care center

• Emergency care as an outpatient at a hospital, including doctors’ services

Note: We waive the ER copay if you are admitted to the hospital.

$150 per visit; waived if admitted

$200 per visit; waived if admitted

Not covered: Elective care or non-emergency care

All charges

All charges

• Emergency care at a doctor’s office

All charges

All charges

• Emergency care at an urgent care center

$50 per visit to an urgent care center

$50 per visit to an urgent care center

• Emergency care as an outpatient at a hospital, including doctor’s services

Note: We waive the ER copay if you are admitted to the hospital.

$150 per visit; waived if admitted

$200 per visit; waived if admitted

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

All charges

All charges

Professional ambulance service when medically appropriate.  (Emergency transport only)

Note: See 5(c) for non-emergency service.

$150 copay

10% after deductible

Air ambulance (emergency transport only)

$150 copay

10% after deductible

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 family therapists. Members may contact Coordinated Behavioral Health Management (CBHM) at 800-444-5755 at any time for direction.

Your cost-sharing responsibilities are no greater than for other illnesses or conditions.

Your cost-sharing responsibilities are no greater than for other illnesses or conditions.

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

$20 copay per visit 

$20 copay per visit 

• Outpatient diagnostic tests provided and billed by a licensed mental health and substance misuse 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

Nothing

10% after deductible

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

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

$100 per day up to a maximum of $500 per admission copay.

10% after deductible

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

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

Nothing

10% after deductible

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

• Drugs and medications approved by the  Food and Drug Administration that by Federal law of the United States require a physician's prescription for their purchase, except those listed as Not covered.

• Insulin

• Diabetic supplies limited to:
     - Disposable needles and syringes for the administration of covered injectable diabetic covered medications
• Drugs for sexual dysfunction
• Drugs to treat gender dysphoria
• Smoking cessation drugs and medications including nicotine patches at no cost
• Vitamin D for adults 65 and older
• Drugs for weight loss limited to one HAP formulary drug from the GLP-1 class for weight loss and at least two additional HAP formulary anti-obesity drugs for members who meet Prior Authorization criteria.

Limitations:

• Refer to the HAP formulary (located at
  www.hap.org/prescription-drug) for any quantity limitations
• Intravenous fluids & medications for home use are covered under Medical and Surgical Benefits.
• Drugs for Erectile dysfunction limited to 6 doses every 30 days
• Up to three cycles per benefit period for IVF-related drugs
• Injectable medications (excluding insulin), specialty medications and opioids are limited to a 30-day supply

Plan (retail) Pharmacy:

• Tier 1- $4 per prescription unit or refill for up to a 30-day supply 
• Tier 2- $10 per prescription unit or refill for up to a 30-day supply 
• Tier 3- $40 per prescription unit or refill for up to a 30-day supply 
• Tier 4- $60 per prescription unit or refill for up to a 30-day supply
• Tier 5- 20% copay per prescription unit or refill up to a $200 max for up to a 30-day supply at specialty pharmacy only 
• Tier 6- 20% copay per prescription unit or refill up to a $200 max for up to a 30-day supply at specialty pharmacy only 

Mail Order:

• Tier 1- $8 per prescription unit or refill for up to a 90-day supply 
• Tier 2- $20 per prescription unit or refill for up to a 90-day supply 
• Tier 3- $80 per prescription unit or refill for up to a 90-day supply 
• Tier 4- $120 per prescription unit or refill for up to a 90-day supply 
• Tier 5- 20% copay per prescription unit or refill up to a $200 max for up to a 30-day supply at specialty pharmacy only 
• Tier 6- 20% copay per prescription unit or refill up to a $200 max for up to a 30-day supply at specialty pharmacy only 

NOTE:  If you receive a brand name drug and a generic substitute is available, you must pay the generic copay plus the difference in cost between the generic and the brand name drug.

Plan (retail) Pharmacy:

• Tier 1- $15 per prescription unit or refill for up to a 30-day supply 
• Tier 2- $25 per prescription unit or refill for up to a 30-day supply 
• Tier 3- $40 per prescription unit or refill for up to a 30-day supply
• Tier 4- $80 per prescription unit or refill for up to a 30-day supply
• Tier 5- 20% copay per prescription unit or refill up to a $200 max for up to a 30-day supply
• Tier 6- 20% copay per prescription unit or refill up to a $200 max for up to a 30-day supply 

Mail Order: 

• Tier 1- $30 per prescription unit or refill for up to a 90-day supply 
• Tier 2- $50 per prescription unit or refill for up to a 90-day supply 
• Tier 3- $80 per prescription unit or refill for up to a 90-day supply 
• Tier 4- $160 per prescription unit or refill for up to a 90-day supply 
• Tier 5- 20% copay per prescription unit or refill up to a $200 max for up to a 30-day supply at specialty pharmacy only 
• Tier 6- 20% copay per prescription unit or refill up to a $200 max for up to a 30-day supply at specialty pharmacy only

NOTE:  If you receive a brand name drug and a generic substitute is available, you must pay the generic copay plus the difference in cost between the generic and the brand name drug.

Contraceptive drugs and devices as listed in the https://www.hrsa.gov/womens-guidelines..

Contraceptive coverage is available at no cost to PSHB members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories of contraception (as well as the screening, education, counseling, and follow-up care). Any contraceptive that is not already available without cost sharing on the formulary can be accessed through the contraceptive exceptions process described below.

Over-the-counter and prescription drugs approved by the FDA to prevent unintended pregnancy.

Physicians who prescribe contraceptives not listed on HAP’s formulary will submit a medical exception request that documents the medical necessity of the non-formulary drug. Upon submission of the medical necessity request by the physician, the drug will be covered at zero cost share. Requests are reviewed based on urgency with a 24-hour turnaround time for urgent cases and a 72-hours turnaround time for standard requests.

Physicians who prescribe brand drugs in place of generics must submit a medical exception request via the prior authorization process that documents the medical necessity of the brand drug. Upon submission of the medical necessity request by the physician, the dispense as written (DAW) drug will be covered at zero cost share. If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.

Reimbursement for covered over-the-counter contraceptives can be submitted in accordance with Section 7.

Note: For additional Family Planning benefits see Section 5 (a)

Nothing for women

Nothing for women

Preventative Medications - Covered

Medications to promote better health as recommended by ACA.

The following drugs and supplements are covered without cost-share, even if over-the-counter, when prescribed by a healthcare professional and filled at a network pharmacy.

• Aspirin (81 mg) for men age 45-79 and women age 55-79 and women of childbearing age
• Folic acid supplements for women of childbearing age 400 & 800 mcg
• Liquid iron supplements for children age 6 months - 1 year
• Vitamin D supplements (prescription strength) (400 & 1000 units) for members 65 or older
• Fluoride tablets, solution ( not toothpaste, rinses) for children age 0-6
• Formulary Statin drugs for the prevention of cardiovascular disease.

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

Please see HAP formulary for complete listing of preventive care product www.hap.org/prescription-drug  

For current recommendations go to
www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations

Nothing: when prescribed by a healthcare professional and filled by a network pharmacy.

Nothing: when prescribed by a healthcare professional and filled by a network pharmacy.

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

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

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

Nothing 

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 • Vitamins, nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them
• Nonprescription medications
• Medical supplies such as dressings and antiseptics
• Compounded medications unless medically necessary
• Replacement of lost/stolen medications
• Devices under the prescription benefit
• Drugs available without a prescription or for which there is a nonprescription equivalent available.
• Women’s contraceptive drugs for men

Note: Formulary over-the-counter and prescription drugs to treat tobacco dependence are covered under the Tobacco cessation benefit. (See page 44.)

All Charges

All Charges

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

• Drugs and medicines that by Federal law of the United States require a physician’s prescription for their purchase, except those listed as Not covered.
• Insulin
• Diabetic supplies limited to:
  • Disposable needles and syringes for the administration of covered medications
• Drugs for sexual dysfunction
• Drugs to treat gender dysphoria
• Medical Foods- See section 5(a) DME
• Sexual dysfunction drugs 
• Fertility drugs-we cover injectable fertility drugs and oral fertility drugs under the prescription drug benefit. 

• Tier 1- $4 per prescription unit or refill for up to a 31-day supply of preferred generic drugs; $8 per prescription unit or refill for a 32-90-day supply of preferred generic drugs
• Tier 2- $10 per prescription unit or refill for up to a 31-day supply of generic drugs; $20 per prescription unit or refill for a 32-90-day supply of generic drug
• Tier 3- $40 per prescription unit or refill for up to a 31-day supply of preferred name drugs; $80 per prescription unit or refill for a 32-90-day supply of preferred name drug
• Tier 4- $60 per prescription unit or refill for up to a 31-day supply of non-preferred name drugs; $120 per prescription unit or refill for a 32-90-day supply of non-preferred name drugs
• Tier 5- 20% copay per prescription unit or refill up to a $200 max for up to a 31-day supply for Specialty Drug(s).

Mail Order:

• Tier 1- $8 per prescription unit or refill for a 32-90-day supply of preferred generic drugs
• Tier 2- $20 per prescription unit or refill for a 32-90-day supply of generic drugs
• Tier 3- $80 per prescription unit or refill for a 32-90-day supply of preferred brand name drugs
• Tier 4- $120 per prescription unit or refill for a 32-90-day supply of non-preferred name drugs

•  NOTE: For 1-31 day-supply prescriptions available at mail, you will pay the applicable one month (1-31 day supply) copay above.

• Tier 1- $4 per prescription unit or refill for up to a 31-day supply of preferred generic drugs; $8 per prescription unit or refill for a 32-90-day supply of preferred generic drugs
• Tier 2- $10 per prescription unit or refill for up to a 31-day supply of generic drugs; $20 per prescription unit or refill for a 32-90-day supply of generic drug
• Tier 3- $40 per prescription unit or refill for up to a 31-day supply of preferred name drugs; $80 per prescription unit or refill for a 32-90-day supply of preferred name drug
• Tier 4- $60 per prescription unit or refill for up to a 31-day supply of non-preferred name drugs; $120 per prescription unit or refill for a 32-90-day supply of non-preferred name drugs
• Tier 5- 20% copay per prescription unit or refill up to a $200 max for up to a 31-day supply for Specialty Drug(s).

Mail Order:

• Tier 1- $8 per prescription unit or refill for a 32-90-day supply of preferred generic drugs
• Tier 2- $20 per prescription unit or refill for a 32-90-day supply of generic drugs
• Tier 3- $80 per prescription unit or refill for a 32-90-day supply of preferred brand name drugs
• Tier 4- $120 per prescription unit or refill for a 32-90-day supply of non-preferred name drugs

•  NOTE: For 1-31 day-supply prescriptions available at mail, you will pay the applicable one month (1-31 day supply) copay above.

Contraceptive drugs and devices as listed in the https://www.hrsa.gov/womens-guidelines.

Contraceptive coverage is available at no cost to PSHB members. The contraceptive benefit includes at least one option in each of the HRSA-supported categories of contraception (as well as the screening, education, counseling, and follow-up care). Any contraceptive that is not already available without cost sharing on the formulary can be accessed through the contraceptive exceptions process described below.

Over-the-counter and prescription drugs approved by the FDA to prevent unintended pregnancy.

Physicians who prescribe contraceptives not listed on HAP’s formulary will submit a medical exception request that documents the medical necessity of the non-formulary drug. Upon submission of the medical necessity request by the physician, the drug will be covered at zero cost share. Requests are reviewed based on urgency with a 24-hour turnaround time for urgent cases and a 72-hours turnaround time for standard requests.

Physicians who prescribe brand drugs in place of generics must submit a medical exception request via the prior authorization process that documents the medical necessity of the brand drug. Upon submission of the medical necessity request by the physician, the dispense as written (DAW) drug will be covered at zero cost share. If you have difficulty accessing contraceptive coverage or other reproductive healthcare, you can contact contraception@opm.gov.

Reimbursement for covered over-the-counter contraceptives can be submitted in accordance with Section 7.

Note: For additional Family Planning benefits see Section 5 (a)

Nothing

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
• Non-prescription medications
• Medical supplies such as dressings and antiseptics
• Compounded medications unless medically necessary
• Devices under the prescription benefit
• Drugs available without a prescription or for which there is a nonprescription equivalent available

All Charges

All Charges

Preventative Medications - Covered

Medications to promote better health as recommended by ACA.

The following drugs and supplements are covered without cost-share, even if over-the-counter, when prescribed by a healthcare professional and filled at a network pharmacy.

• Aspirin (81 mg) for men age 45-79 and women age 55-79 and women of childbearing age
• Folic acid supplements for women of childbearing age 400 & 800 mcg
• Liquid iron supplements for children age 6 months - 1 year
• Vitamin D supplements (prescription strength) (400 & 1000 units) for members 65 or older
• Fluoride tablets, solution ( not toothpaste, rinses) for children age 0-6
• Formulary Statin drugs for the prevention of cardiovascular disease.

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

For current recommendations go to 
www.uspreventiveservicestaskforce.org/BrowseRec/Index/browse-recommendations

Nothing: when prescribed by a healthcare professional and filled by a network pharmacy.

Nothing: when prescribed by a healthcare professional and filled by a network pharmacy.

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

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

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

Nothing

Nothing 

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.

Emergency/urgent care copay may apply

Emergency/urgent care copay may apply

We have no other dental benefits

Not covered

Not covered

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).

HAP Telecommunications Device for the Deaf (TDD) 800-649-3777

24 hours a day, seven days a week

Medically necessary services for high-risk pregnancies are covered, consistent with the Member's subscriber documents and are subject to any criteria for specific services that may exist in other policies.

If you are more comfortable with a language other than English, call Customer Service at 800-556-9765 to arrange for translation services. This is a free service.

Assist America – www.assistamerica.com/hap

See Section 5 Non-PSHB benefits available to Plan members for more information.

HAP Members enrolled in Medicare Part A and Part B are eligible to be reimbursed up to $800 per calendar year for their Medicare Part B premium payments, $1200 per calendar year if  you enroll into our MAPD Standard option, and $1800 per calendar year if you enroll into our MAPD High Option. An account is set up and used to reimburse member-paid Medicare Part B premiums by either direct deposit or check. For more information on how this program works and how to receive reimbursement, call; 800-556-9765 or visit www.hap.org/fehb/member-benefits/pshb.

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 313-664-8757 or 800-556-9765, or at our website at www.hap.org.

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

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

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

Submit your claims to:

Health Alliance Plan

1414 E. Maple Rd.

Troy MI 48083.

For Commercial Non-PDP plans Submit your claims to:

Health Alliance Plan

1414 E. Maple Rd.

Troy MI 48083.

800-556-9765

www.hap.org

For PDP Post-service claims procedures

Express Scripts Medicare (for Medicare Part D Prescription Drug Plan EGWP only)

See your Express Scripts Medicare Evidence of Coverage CHAPTER 5: Asking us to pay our share of the costs for covered drugs, SECTION 3 We will consider your request for payment and say yes or no and CHAPTER 7: What to do if you have a problem or complaint (coverage decisions, appeals, complaints), SECTION 4 A guide to the basics of coverage decisions and appeals. Your EOC is located on the Express Scripts member portal at www.express-scripts.com.

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

We will notify you of our decision within 30 days after we receive your post-service claim. If matters beyond our control require an extension of time, we may take 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, a healthcare professional with knowledge of your medical condition will be permitted to act as your authorized representative without your express consent. For the purposes of this section, we are also referring to your authorized representative when we refer to you.

If you live in a county where at least 10% of the population is literate only in a non-English language (as determined by the Secretary of Health and Human Services), we will provide language assistance in that non-English language. You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as 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: HAP Grievances, 1414 E. Maple Rd. Troy MI 48083; and

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

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

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

We will provide you, free of charge and in a timely manner, with any new or additional evidence considered, relied upon, or generated by us or at our direction in connection with your claim and any new rationale for our claim decision. We will provide you with this information sufficiently in advance of the date that we are required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond to us before that date. However, our failure to provide you with new evidence or rationale in 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, Postal Service Insurance Operations (PSIO), 1900 E Street, room 3443, NW, Washington, DC 20415

Send OPM the following information:

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

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

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

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

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

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

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

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

Note: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call us at  800-556-9765 . We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal. You may call OPM’s Health Insurance-PSIO at 202-936-0002 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.

Reminder: If you are a Postal Service annuitant, or their covered Medicare-eligible family member, enrolled in our Medicare Part D PDP EGWP you may appeal an adverse pre-service or post-service determination through Medicare's appeals process. See Section 8(a).

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.hap.org/pshb

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.

Please see Section 4, Your Costs for Covered Services, for more information about how we pay claims.

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

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

We do not cover services that:

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

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

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

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

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

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

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

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

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

Important Note: Subject to limited exceptions, Postal Service annuitants entitled to Medicare Part A and their eligible family members who are entitled to Medicare Part A are required to enroll in Medicare Part B to maintain eligibility for the PSHB Program in retirement.

If you are required to enroll in Medicare Part B and fail to do so at your first opportunity, you may be disenrolled (annuitants) and/or your family members removed from coverage. 

For more information on these requirements, please contact 800-556-9765.

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

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

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

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

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

When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 313-664-8757 or 800-556-9765 or you may write to the Plan at HAP Customer Service, 1414 E Maple rd. Troy Mi 48083 or see our website at www.hap.org.

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

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

HIGH OPTION PLAN

Benefit Description: Deductible
You Pay without Medicare: $0
You Pay with Medicare Part B: $0

Benefit Description: Out of Pocket Maximum
You Pay without Medicare: $6,350 Self only/$12,700 Self Plus one or Self and Family
You Pay with Medicare Part B: $6,350 Self only/$12,700 Self Plus one or Self and Family

Benefit Description: Part B Premium Reimbursement Offered
You Pay without Medicare: N/A
You Pay with Medicare Part B: you earn up to $800 per year

Benefit Description: Primary Care provider.
You Pay without Medicare: $20
You Pay with Medicare Part B: $20 or less

Benefit Description: Specialist
You Pay without Medicare: $40
You Pay with Medicare Part B: $40 or less

Benefit Description: Inpatient Hospital
You Pay without Medicare: $100 per day up to a maximum of $500 per admission copay.
You Pay with Medicare Part B: $100 per day up to a maximum of $500 per admission copay, or less

Benefit Description: Outpatient Hospital
You Pay without Medicare: Nothing per visit
You Pay with Medicare Part B: Nothing per visit

Benefit Description: Incentives Offered
You Pay without Medicare: N/A
You Pay with Medicare Part B: N/A

STANDARD OPTION PLAN

Benefit Description: Deductible
You Pay without Medicare: $350 self only/$700 self plus one or self and family
You Pay with Medicare Part B: $350 self only/$700 self plus one or self and family

Benefit Description: Out-of-Pocket Maximum
You Pay without Medicare: Nothing after $6,350 Self only/$12,700 Self Plus one or Self and Family
You Pay with Medicare Part B: Nothing after $6,350 Self only/$12,700 Self Plus one or Self and Family

Benefit Description: Part B Premium Reimbursement Offered
You Pay without Medicare: N/A
You Pay with Medicare Part B: you earn up to $800 per year

Benefit Description: Primary Care provider.
You Pay without Medicare: You pay nothing for preventive services. Office visit copay is $20 for primary care.
You Pay with Medicare Part B: You pay nothing for preventive services. Office visit copay is $20 for primary care or less

Benefit Description: Specialist
You Pay without Medicare: $50
You Pay with Medicare Part B: $50 or less

Benefit Description: Inpatient Hospital
You Pay without Medicare: 10% coinsurance after deductible
You Pay with Medicare Part B: 10% coinsurance after deductible or less

Benefit Description: Outpatient Hospital
You Pay without Medicare: 10% coinsurance after deductible
You Pay with Medicare Part B: 10% coinsurance after deductible or less

Benefit Description: Incentives Offered
You Pay without Medicare: N/A
You Pay with Medicare Part B: N/A

We offer a Medicare Advantage plan, the HAP PSHB Medicare Advantage plan for High Option PSHB plan members or the HAP PSHB Medicare Advantage plan for Standard Option PSHB plan members. Please review the plan option information for these options under Medicare Part C below. 

You can find more information about how our plan coordinates benefits with Medicare on our member portal at www.hap.org/PSHB.

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

This Plan and our HAP Medicare Advantage plan: You may enroll in our HAP Medicare Advantage plan and also remain enrolled in our PSHB plan. for more information on our Medicare Advantage plan, please call 833-HAP-HERE or 833-427-4373 or visit our website at www.hap.org/PSHB. Enrollment in the HAP Medicare Advantage plan is voluntary.  Members must complete an application for enrollment.  Eligible enrollees voluntarily opt into the HAP Medicare Advantage plan and can opt out at anytime.  you many enroll in the HAP Medicare Advantage plan if: 

• You are a retiree or annuitant and enrolled in HAP's High or Standard Option and have both Medicare Part A & B
• You are a united states citizen or are lawfully present in the United States, the District of Columbia, or a US territory
• You do Not have End Stage Renal Disease (ESRD). Enrollees who have ESRD cannot enroll until after the 30-month grace period has expired. Members diagnosed with ESRD while enrolled in the HAP Medicare Advantage Plan may remain enrolled and ESRD services will be covered

You complete an application for enrollment in the HAP Medicare Advantage Plan (see contact information above)

When you are enrolled in the HAP Medicare Advantage Plan you receive the following additional benefits, including:

• Medicare Part B Premium Subsidy: $100 for Standard Plan per month, $150 for High Plan per month
• Visitor/Traveler – Enjoy in-network prices for copays on plan covered routine services when visiting any Medicare-participating provider in Arizona, Florida, Michigan (out-of-service area), and Texas for up to 12 months. 
• SilverSneakers® - An exercise program designed exclusively for older adults.  SilverSneakers offers physical activity, health education, and social events for people who are Medicare-eligible and Group Retiree members

To learn more about benefit enhancements offered for the HAP Medicare Advantage
Plan, please contact 833-HAP-HERE or 833-427-4373  or www.hap.org/PSHB 

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

If you are enrolled in Medicare Part A and/or Part B, and are not enrolled in our Medicare Advantage Prescription Drug Plan (MAPD), you will be automatically group enrolled into our Medicare PDP EGWP. Our PDP EGWP is a prescription drug benefit for Postal Service annuitants and their covered Medicare-eligible family members.

This allows you to receive benefits that will never be less than the standard prescription drug coverage that is available to members with non-PDP EGWP prescription drug coverage. But more often you will receive benefits that are better than members with standard non-PDP EGWP prescription drug coverage. Note: You have the choice to opt out of or disenroll from our PDP EGWP at any time and may obtain prescription drug coverage outside of the PSHB Program.

When you are enrolled in our Medicare PDP EGWP for your prescription drug benefits you continue to have our medical coverage.

Members with higher incomes may have a separate premium payment for their Medicare Part D Prescription Drug Plan (PDP) 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.

For people with limited income and resources, Extra Help is a Medicare program to help with Medicare prescription drug plan costs.  Information regarding this program is available through the Social Security Administration (SSA) online at www.socialsecurity.gov , or call the SSA at 800-772-1213  TTY 800-325-0778.  You may also contact 800.236.4782

The PDP EGWP opt out process:

If you were automatically group enrolled into our PDP EGWP and choose to opt out contact us at 800.236.4782

The PDP EGWP disenrollment process:

When you are enrolled in our PDP EGWP, you may choose to disenroll at any time. Contact us at 800.236.4782

Warning:  If you opt out of or disenroll from our PDP EGWP, you will not have any PSHB Program prescription drug coverage. However, you can enroll in our MAPD during Open Season or for a QLE and receive PSHB Program Prescription Drug Coverage. To enroll into our MAPD plan, call 833-HAP-HERE or 833-437-4373. 

Note:  If you choose to opt out of or disenroll from our PDP EGWP, your premium will not be reduced, and you may have to wait to re-enroll when and if you are eligible.  If you do not maintain creditable coverage, re-enrollment in our PDP EGWP may be subject to a late enrollment penalty. Contact us for assistance at 800.236.4782

When we are the primary payor, we process the claim first.  If you (as an active employee eligible for Medicare Part D or their covered Medicare Part D-eligible family member) enroll in any open market Medicare Part D plan and we are the secondary payor, we will review claims for your prescription drug costs that are not covered by that Medicare Part D plan and consider them for payment under the PSHB plan. 

Note: If you are a Postal Service annuitant or their covered Medicare-eligible family member enrolled in our Medicare Part D PDP EGWP, this does not apply to you because you may not be enrolled in more than one Medicare Part D plan at the same time.  If you opt out of or disenroll from our PDP EGWP you do not have our PSHB Program prescription drug coverage and we are not a secondary payor for prescription drug benefits.

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

• You have PSHB 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.

A request for your health insurer or plan to review a decision, pre-service claim or post-service claim again

Maximum amount on which payment is based for covered health care services. This may be called "eligible expense," "payment allowance" or "negotiated rate.

The beneficiary of an annuity or pension. 

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

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

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

See Section 4, page 23

See Section 4, page 23

See Section 4, page 23

Care we provide benefits for, as described in this brochure.

The medical or non-medical services which do not seek to cure, are provided during periods when the medical condition of the patient is not changing, or do not require the continued administration of medical personnel.

See Section 4, page 25

Medical, psychiatric, substance abuse or other health care services, supplies, treatments, drug therapies or devices that are determined by the health plan.

For the purposes of this Contract, HAP bases its determination of whether or not a drug, treatment, device, procedure, service or benefit is experimental or investigational in nature if it meets any of the following criteria:

• It cannot be lawfully marketed without the approval of the FDA and such approval has not been granted at the time of its use or its proposed use; or is the subject of current investigational new drugs or device applications with the FDA.
• It is being provided pursuant to Phase I or Phase II clinical trial or as the experimental or research arm of Phase III clinical trial; or is the subject of written protocol which describes its objective, determinations of safety, efficacy, efficacy in comparison to conventional alternatives of toxicity.
• It is being delivered or should be delivered subject to the approval and supervision of an Institutional Review Board as required and defined by federal regulations, particularly those to the FDA or the Department of Health and Human Service.
• The predominant opinion among experts as expressed in the published authoritative literature is that the usage should be substantially confined to research settings; or it is not investigational in itself pursuant to any of the foregoing criteria, and would not be medically necessary, but for the provision of a drug, device treatment, or procedure which is “investigational or experimental.”
• Medical services that are generally regarded by the medical community to be unusual, infrequently provided and not necessary for the protection of health

A health benefits plan that covers a group of people, such as employees of a company, as permitted by state and federal law

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

Infertility is defined as not being able to get pregnant (conceive) after one year (or longer) of unprotected sex or artificial insemination for individuals under the age of 35.  Because fertility in some individuals is known to decline steadily with age, some providers evaluate and treat members aged 35 years or older after 6 months of unprotected sex or artificial insemination. Infertility may also be established through evidence of medical history and diagnostic testing

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

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

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

A carrier's pursuit of a recovery from any party that may be liable, any applicable insurance policy, or a workers' compensation program or insurance policy, as successor to the rights of a covered individual who suffered an illness or injury and has obtained benefits from that carrier's health benefits plan.

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.

Us and We refer to

You refers to the enrollee and each covered family member.

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 toll-free at 800-556-9765. 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.

An abbreviation for Health Alliance Plan.

Health care services or supplies needed to prevent, diagnose or treat an illness, injury, condition, disease or its symptoms and that meet accepted standards of medicine.

A decision by your health insurer or plan that a health care service, treatment plan, prescription drug or durable medical equipment is medically necessary. Sometimes called prior authorization, prior approval or precertification. Your health plan may require preauthorization for certain services before you receive them, except in an emergency. Preauthorization isn’t a promise your health insurance or plan will cover the cost.

Part A helps cover inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care.

Part B covers medically necessary services like doctors’ services and tests, outpatient care, home health services, durable medical equipment, and other medical services.

Part C is a Medicare Advantage plan that combines the coverage of Medicare Part A and Part B.  Part C typically also covers additional benefits like, dental, vision, and hearing services. Some Part C plans also include Medicare Part D coverage.

Medicare Part D plans provide coverage for prescription drugs. Private insurers contract with CMS on an annual basis for the right to offer Part D plans. Part D can be offered as a standalone Prescription Drug Plan (PDP) or as part of a Medicare Advantage Prescription Drug Plan (MAPD).

A Medicare Part D Employer Group Waiver Plan (EGWP) is a type of Medicare prescription drug plan that can be offered to employees and retirees of certain companies, unions, or government agencies, which allows for flexibility and enhanced coverage of traditional Medicare pharmacy benefits. Examples of Medicare Part D EGWPs are Medicare Advantage Prescription Drug (MAPD) plan EGWPs that include both health and drug benefits, as well as Prescription Drug Plan (PDP) EGWPs, which only cover the prescription drug benefit.

Office visit copay: $20 primary care; $40 specialist

28

$100 per day up to a maximum of $500 per admission copay.

46

$250

47

$150 per visit to ER/Waived if admitted

50

$150 per visit to ER/Waived if admitted

50

Regular cost-sharing

51

$4 preferred generic/$10 non-preferred generic/ $40 preferred brand/$60 non-preferred brand/ 20% preferred specialty/ 20% non-preferred specialty.

53

$4 preferred generic/$10 non-preferred generic/ $40 preferred brand/$60 non-preferred brand/ 20% preferred specialty/ 20% non-preferred specialty.

67

$8 preferred generic/$20 non-preferred generic/ $80 preferred brand/$120 non-preferred brand. 

67

Limited benefit – exams only, $0 copay

39

No benefit

60

Nothing after $6,350 for Self-Only enrollment, $12,700 for Self Plus One coverage or $12,700 for Self and Family coverage. Some costs do not count toward this protection

22

Office visit copay: $20 primary care; $50 specialist, after deductible

28

10% coinsurance per admission after deductible*

46

10% after deductible

47

$200 per visit/Waived if admitted

50

$200 per visit/ Waived if admitted

50

Regular cost-sharing

51

$15 preferred generic/$25 non-preferred generic/ $40 preferred brand/$80 non-preferred brand/ 20% preferred specialty/ 20% non-preferred specialty.

53

$4 preferred generic/$10 non-preferred generic/ $40 preferred brand/$60 non-preferred brand/ 20% preferred specialty/ 20% non-preferred specialty.

67

$30 preferred generic/$50 non-preferred generic/ $80 preferred brand/$160 non-preferred brand

53

No benefit.

95

Limited benefit – exams only, $0 copay

39

Nothing after $6,350 for Self-Only enrollment, $12,700 for Self Plus One coverage or $12,700 for Self and Family coverage

22