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 https://health-benefits.opm.gov/PSHB/. For assistance with the PSHB System, call the PSHB 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 26th birthday unless your child is eligible for continued coverage because they are incapable of self-support due to a physical or mental disability that began before age 26.

If you or one of your family members is enrolled in one 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 www.opm.gov/healthcare-insurance/life-events. 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 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.

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).

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage and premiums begin 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).

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.

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 844-440-1900.

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 844-440-1900 or visit our website at www.healthpartners.com/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.

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 844-440-1900 (TTY: 711) or write to us at Riverview Member Services, PO Box 21662, Eagan, MN 55121. You may also request replacement cards through our website at www.healthpartners.com/pshb.

In-Network: You get care from "Plan providers" and "Plan facilities." You will pay copayments, deductibles, and/or coinsurance. You can receive covered services from a participating provider without a referral from your primary care provider or another participating provider in the network.

Out-of-Network (Standard Option): You may choose to use your out-of-network benefits and receive care from any licensed provider. You may be billed for these services and may need to file a claim for reimbursement.

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

Plan providers are physicians and other healthcare professionals in our service area that we contract with to provide covered services to our members. 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 HealthPartners Open Access Network provider directory, which we update periodically. For information that is updated weekly, visit www.healthpartners.com/pshb.

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

This plan provides Care Coordinators for complex conditions and can be reached at 952-883-5469 or 800-871-9243 for assistance.

This Plan lets you receive care from more than 850,000 providers in the Open Access Network. Referrals are not required and you do not need to choose a primary care clinic. Any time you or a member in your family needs care, you may choose to see any provider in this network.

High Option: With limited exceptions, if you seek care from a provider who does not participate in the Open Access Network, your care is considered out-of-network and may not be covered.

Standard Option: With limited exceptions, if you seek care from a provider who does not participate in the Open Access Network, your care is considered out-of-network and the lower out-of-network benefits apply.

Plan facilities are hospitals and other facilities that we contract with to provide covered services to our members. We list these in the Open Access Network provider directory, which we update periodically. The list is on our website: www.healthpartners.com/pshb.

High Option: With limited exceptions, if you seek care from a facility that does not participate in the Open Access Network, your care is considered out-of-network and may not be covered.

Standard Option: With limited exceptions, if you seek care from a facility that does not participate in the Open Access Network, your care is considered out-of-network and the lower out-of-network benefits apply.

High Option: Any time you or a member in your family needs care, you should choose to see any provider in the Open Access Network. With limited exceptions, if you seek care from a provider who does not participate in the Network your care is considered out-of-network and may not be covered.

Standard Option: Any time you or a member in your family needs care, you should choose to see any provider in the Open Access Network. You may choose to use your out-of-network benefit and receive care from any licensed provider. You may be billed for these services and may need to file a claim for reimbursement.

Members are not required to pick a primary clinic. However, we encourage members to work with personal physicians who will get to know them. Primary care providers are providers in the following categories: family and general practice, internal medicine, pediatrics, adolescent medicine, adult medicine and geriatrics. Your primary care provider will provide most of your healthcare or suggest that you see a specialist. You can see any specialist without a referral.

If you want to change your primary care provider or if your primary care provider leaves the Plan, simply choose another provider from the Open Access Network directory for in-network benefits. For the most up-to-date network provider information, visit www.healthpartners.com/pshb, where information is updated weekly.

Specialty care providers are providers who are not in the following categories: family and general practice, internal medicine, pediatrics, adolescent medicine, adult medicine and geriatrics.

You have direct access to any specialist in the Open Access Network without a referral.

If you are seeing a specialist when you enroll in our Plan and your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.

If you are seeing a specialist and your specialist leaves the Plan, you may be able to continue seeing your provider for a period of time, please see Continuity of care for more information.

If you are seeing a provider when you enroll in our Plan and your current provider does not participate with us, you must receive treatment from a provider who does. Generally, we will not pay for you to see a provider who does not participate with our Plan. However, in the event you must change your current primary care provider, specialty care provider or general hospital provider because that provider leaves the Open Access Network, HealthPartners drops out of the Postal Service Employees Health Benefits (PSHB) Program and you enroll in another PSHB plan; or HealthPartners reduces our Service Area and you enroll in another PSHB plan, you may be able to continue seeing your provider for a period of time. Some services provided by out-of-network providers may be considered a covered benefit for up to 120 days under this Plan if you qualify for continuity of care benefits under state or federal law.

Conditions that qualify for this benefit are:

• an acute condition;
• a life-threatening mental or physical illness;
• pregnancy for which you have begun care;
• a physical or mental disability defined as an inability to engage in one or more major life activities, provided that the disability has lasted or can be expected to last for at least one year, or can be expected to result in death; or
• a disabling or chronic condition that is in an acute phase.

You may also request continuity of care benefits for culturally appropriate services or when we do not have a provider who can communicate with you directly or through an interpreter.

Terminally ill patients are also eligible for continuity of care benefits. Continuity of care may continue for the rest of the enrollee's life if a physician, advanced practice registered nurse, or physician assistant certifies that the enrollee has an expected lifetime of 180 days or less.

Continuity of care benefits will not be available or may be discontinued if the provider is terminated from the network for misconduct.

Call Member Services for further information regarding continuity of care benefits, or if we drop out of the Program, contact your new plan.

You may be required to see a designated provider for transplants and bariatric surgery. A designated provider is a healthcare provider, group or association of healthcare providers designated by us to provide services, supplies or drugs for specified transplants or bariatric surgery.

Your 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 HealthPartners Member Services immediately at 844-440-1900 (TTY: 711). 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 FEHB plan to this PSHB plan, 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 first.

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.

We cover eligible services only when medically necessary for the proper treatment of a member. Our medical or dental directors, or their designees, make coverage determinations of medical necessity, restrictions on access and appropriateness of treatment, and they make final authorization for covered services. Coverage determinations are based on the terms of this brochure and our coverage criteria policies, which are subject to periodic review and modification by the medical or dental directors. Coverage determinations for prescription drugs are based on requirements established by the HealthPartners Pharmacy and Therapeutics Committee, and are subject to periodic review and modification.

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.

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

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

We call this review and approval process prior authorization. Your physician must obtain prior authorization for services such as:

• Reconstructive surgery
• Promising therapies/new technologies
• Transplants
• Medically necessary dental care, such as orthognathic surgery
• Durable medical equipment and prosthetics
• Home health care
• Skilled nursing care
• Hospice care
• Habilitative therapy
• Bariatric surgery
• Growth hormone therapy (GHT)
• Gender affirming (confirmation) surgery

The complete list, along with the criteria we use to review authorization requests, is available on
www.healthpartners.com/pshb or by calling HealthPartners Member Services at 844-440-1900 (TTY: 711). Your physician is responsible for obtaining prior authorization.

First your physician, your hospital, you, or your representative, must call us at 952-883-6333 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
• Number of days requested for hospital stay

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

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

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

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

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

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM. Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us at 844-440-1900 (TTY: 711). 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 844-440-1900 (TTY: 711). If it is determined that your claim is an urgent care claim, we will expedite our review (if we have not yet responded to your claim).

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

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

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

Inpatient delivery does not require precertification or prior authorization from us. 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.

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

If you request an extension of an ongoing course of treatment at least 24 hours prior to the expiration of the approved time period and this is also an urgent care claim, we will make a decision within 72 hours after we receive the claim.

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

If you have a pre-service claim and you do not agree with our decision regarding prior approval of other services, you may request a review in accord with the procedures detailed below. If your claim is in reference to a contraceptive, call 844-440-1900.

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

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

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

1. Precertify your hospital stay or, if applicable, arrange for the 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.

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

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

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) of this brochure and Chapter 7 of the Prescription Drug Plan Evidence of Coverage for information about the PDP EGWP appeal process.

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: With High Option, when you see your primary care provider, you pay a copayment of $45 per office visit.

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

Any amounts paid or reimbursed by a third party, including but not limited to: point of service rebates, manufacturer coupons, debit cards or other forms of direct reimbursement to an enrollee for a product or service, will not apply toward your deductible.

High Option: The High Option plan includes a $500 calendar year deductible specific only to inpatient and outpatient hospital services and MRI/CT scans.

Standard Option:
For Network Expenses: The calendar year deductible is $750 for persons enrolled for Self Only coverage, $1,500 for persons enrolled for Self Plus One coverage and $1,500 for families enrolled for Self and Family coverage. Under a Self Only enrollment, the deductible is considered satisfied and benefits are payable for you when your covered expenses applied to the calendar year deductible for your enrollment reach $750. Under a Self Plus One enrollment, the deductible is considered satisfied and benefits are payable to you and one other eligible family member when the combined covered expenses applied to the calendar year deductible for your enrollment reach $1,500. 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 $1,500.

For Out-of-Network Expenses: The calendar year deductible is $2,000 for persons enrolled for Self Only coverage $4,000 for persons enrolled for Self Plus One coverage and $4,000 for families enrolled for Self and Family coverage. Under a Self Only enrollment, the deductible is considered satisfied and benefits are payable for you when your covered expenses applied to the calendar year deductible for your enrollment reach $2,000. Under a Self Plus One enrollment, the deductible is considered satisfied and benefits are payable to you and one other eligible family member when the combined covered expenses applied to the calendar year deductible for your enrollment reach $4,000. Under a Self and Family enrollment, the deductible is considered satisfied and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reach $4,000.

Note: If you change 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 old option to the deductible of your new option.

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

Example: In our Plan, you pay 20% 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.

Any amounts paid or reimbursed by a third party, including but not limited to: point of service rebates, manufacturer coupons, debit cards or other forms of direct reimbursement to an enrollee for a product or service, will not apply to your catastrophic protection out-of-pocket maximum.

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.

High Option: If you are enrolled for Self Only coverage, when your copayments and/or coinsurance total $6,500 in a calendar year, you do not have to pay any more for covered services for the remainder of that calendar year.

If you are enrolled for Self Plus One coverage, when you and your dependent's copayments and/or coinsurance total $13,000 in a calendar year, you and your dependent do not have to pay any more for covered services for the remainder of that calendar year. However, each enrollee will not pay more than $9,200 in a calendar year.

If you are enrolled for Self and Family coverage, when your family’s copayments and/or coinsurance total $13,000 in a calendar year, you and your dependents do not have to pay any more for covered services for the remainder of that calendar year. However, each enrollee will not pay more than $9,200 in a calendar year.

Standard Option: In-Network: If you are enrolled for Self Only coverage, when your deductible, copayments and/or coinsurance total $7,500 in a calendar year, you do not have to pay any more for covered services for the remainder of that calendar year.

If you are enrolled for Self Plus One coverage, when you and your dependent's, deductible, copayments and/or coinsurance total $15,000 in a calendar year, you and your dependent do not have to pay any more for covered services for the remainder of that calendar year. However, each enrollee will not pay more than $9,200 in a calendar year.

If you are enrolled for Self and Family coverage, when your family’s deductible, copayments and/or coinsurance total $15,000 in a calendar year, you and your dependents do not have to pay any more for covered services for the remainder of that calendar year. However, each enrollee will not pay more than $9,200 in a calendar year.

Out-of-Network: There is no limit on your out-of-pocket expenses.

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 due to a qualifying life event (QLE) during the year, we will credit the amount of covered expenses already accumulated toward the catastrophic out-of-pocket limit of your prior option to the catastrophic protection limit of your new option.

Facilities of the Department of Government Affairs, the Department of Defense and the Indian Health Services are entitled to seek reimbursement 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 any state surprise billing laws, as may be applicable, in Minnesota, Wisconsin, Iowa, North Dakota, South Dakota.

Provisions of the No Surprises Act do not apply to out-of-network claims from providers that are outside of the US or US territories. Coverage level for services received outside of these areas is the same as corresponding out-of-network Benefits (if available), depending on the type of service provided.

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to www.healthpartners.com/pshb or contact the health plan at 844-440-1900 (TTY: 711).

We cover professional services of physicians:

• In an office
• Office medical consultations
• Scheduled telephone visits
• Second surgical opinion
• Testing and treatment of sexually transmitted diseases and testing for HIV and HIV-related conditions provided by a Plan or non-Plan provider

Note: List of qualifying clinics is available at
www.healthpartners.com/pshb.

$45 per office visit

If other services are performed during the visit, such as diagnostic imaging or laboratory services, additional Deductible, Copayment or Coinsurance may apply. Diagnostic imaging services and laboratory services are covered under the "Lab, X-ray and other diagnostic tests" benefit.

In-Network: $0 for the first 5 office, convenience clinic, telephone, urgent care visits, evisits and video visits combined in a calendar year (deductible does not apply), then 20% of charges, subject to the in-network deductible. Physician’s services, laboratory and radiology performed in conjunction with the same visit and on the same date of service are included; however, charges for day treatment services, group visits, office procedures and other ancillary services are not included and will be subject to your deductible and coinsurance.

Out-of-Network: 40% of charges after out-of-network deductible

• At a convenience clinic

Note: For a list of convenience clinics, see your provider directory, call Member Services or visit our website at www.healthpartners.com/pshb.

In-Network: $0 for the first 5 office, convenience clinic, telephone, urgent care visits, evisits and video visits combined in a calendar year (deductible does not apply), then 20% of charges, subject to the in-network deductible. Physician’s services, laboratory and radiology performed in conjunction with the same visit and on the same date of service are included; however, charges for day treatment services, group visits, office procedures and other ancillary services are not included and will be subject to your deductible and coinsurance.

Out-of-Network: 40% of charges after out-of-network deductible

• E-visit or chat based visits

We cover asynchronous online or mobile app encounters to discuss a patient’s personal health information, vital signs, and other physiologic data or diagnostic images. The healthcare provider reviews and delivers a consultation, diagnosis, prescription or treatment plan after reviewing the patient’s visit information

$10 per visit.

In-Network: $0 for the first 5 office, convenience clinic, telephone, urgent care visits, evisits and video visits combined in a calendar year (deductible does not apply), then 20% of charges, subject to the in-network deductible.

Physician’s services, laboratory and radiology performed in conjunction with the same visit and on the same date of service are included; however, charges for day treatment services, group visits, office procedures and other ancillary services are not included and will be subject to your deductible and coinsurance.

Out-of-Network: 40% of charges after out-of-network deductible

• Video Visits

We cover live, synchronous interactive encounters using secure web-based video between a patient and a healthcare provider.

$45 per office visit

$500 hospital deductible for inpatient and outpatient hospital services combined, then 20% of inpatient hospital charges

In-Network office visits: $0 for the first 5 office, convenience clinic, telephone, urgent care visits, evisits and video visits combined in a calendar year (deductible does not apply), then 20% of charges, subject to the in-network deductible. Physician’s services, laboratory and radiology performed in conjunction with the same visit and on the same date of service are included; however, charges for day treatment services, group visits, office procedures and other ancillary services are not included and will be subject to your deductible and coinsurance.

In-Network hospital visits: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

• Through Virtuwell^®, our online benefits program at www.Virtuwell.com

Nothing.

Nothing.

• In an urgent care center

$45 per office visit

If other services are performed during the visit, such as diagnostic imaging or laboratory services, additional Deductible, Copayment or Coinsurance may apply. Diagnostic imaging services and laboratory services are covered under the "Lab, X-ray and other diagnostic tests" benefit.

In- or Out-of-Network: $0 for the first 5 office, convenience clinic, telephone, urgent care visits, evisits and video visits combined in a calendar year (deductible does not apply), then 20% of charges, subject to the in-network deductible. Physician’s services, laboratory and radiology performed in conjunction with the same visit and on the same date of service are included; however, charges for day treatment services, group visits, office procedures and other ancillary services are not included and will be subject to your deductible and coinsurance.

• Specialty drugs administered in an office

We cover specialty drugs that are used to treat chronic health conditions including but not limited to such conditions as transplant recipients, immunological conditions, growth hormone, bleeding disorder, HIV/AIDS. We require prior authorization for certain drugs and the site where the drug will be administered.

40% of charges

In-Network: 40% of charges, after deductible

Out-of-Network: All charges

• During a hospital stay
• In a skilled nursing facility

$500 hospital deductible for inpatient and outpatient hospital services combined, then 20% of inpatient hospital charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

• At home physical therapy, occupational therapy, speech therapy, respiratory therapy and home health aide services

$45 per visit

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

• Injections administered in a Physician’s office or Outpatient Facility, including professional administration of Drugs and blood products

For allergy injections, see Allergy care on page (Applies to printed brochure only)

15% of charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

We cover tests, such as:

• Blood tests
• Urinalysis
• Non-routine pap test
• Pathology
• Routine prostate specific antigen (PSA) testing for individuals 40 years of age or over who are symptomatic or in a high-risk category and for all individuals 50 years of age or older

$45 per visit

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

• X-ray
• Non-routine mammogram
• Ultrasound
• Electrocardiogram and EEG

20% of charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

• CT/CAT Scan
• MRI

$500 hospital deductible for inpatient and outpatient hospital services combined, then 20% of charges. The hospital deductible applies even for services received in an office.

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

Routine physicals

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

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

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

Nothing

In-Network: Nothing

Out-of-Network: 40% of charges after out-of-network deductible

• Routine hearing and eye exams

Nothing

In-Network: Nothing

Out-of-Network: 40% of charges after out-of-network deductible

• Routine 2D and 3D mammogram

Nothing

In-Network: Nothing

Out-of-Network: 40% of charges after out-of-network deductible

• Adult routine 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/

Nothing

In-Network: Nothing

Out-of-Network: 40% of charges after out-of-network deductible

• Tobacco use screening and interventions

Nothing

In-Network: Nothing

Out-of-Network: 40% of charges after out-of-network deductible

We cover online account, online health assessment and online wellness courses

$250 incentive, in the form of a HealthPartners Wellness Account debit card to be used towards most qualified medical expenses, for each adult employee or covered spouse who registers for online services and completes an online health assessment and an eligible online health improvement program (Limit one incentive per adult employee or covered spouse per calendar year).

Total maximum incentive amount is $250 Self and $500 Family.

Additional information is available at www.healthpartners.com/pshb

$250 incentive, in the form of a HealthPartners Wellness Account debit card to be used towards most qualified medical expenses, for each adult employee or covered spouse who registers for online services and completes an online health assessment and an eligible online health improvement program (Limit one incentive per adult employee or covered spouse per calendar year).

Total maximum incentive amount is $250 Self and $500 Family.

Additional information is available at www.healthpartners.com/pshb

Obesity counseling, screening and referral for those persons at or above the USPSTF obesity prevention risk factor level, 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, including weight management classes and individual and group behavior counseling sessions as described in our Coverage Criteria available at www.healthpartners.com/public/coverage-criteria/.
• Family centered programs when medically identified to support obesity prevention and management by an in-network provider. This includes group counseling, diabetes education/classes, nutrition education/classes, community health workers, diabetes prevention and weight management as described in our Coverage Criteria available at www.healthpartners.com/public/coverage-criteria/.

Notes: Also see Section 5(h) for additional nutritional and physical activity support

• When anti-obesity medication is prescribed as indicated by the FDA obesity medication treatment guidelines. See Section 5(f) or 5(f)(a), if applicable, for cost share requirements for anti-obesity medications.
• When Bariatric or Metabolic surgical treatment or intervention is indicated for severe obesity. See Section 5(b) for surgery requirements and cost share.

Nothing

In-Network: Nothing

Out-of-Network: 40% of charges after out-of-network deductible

Not covered:

Any health services, certifications or examinations required by a third party when not otherwise medically necessary or eligible preventive care. This includes, but is not limited to, services:

• To get or keep a job, including vocational assessments
• Required under a labor agreement or other contract
• Needed for legal proceedings. This includes, but is not limited to, services related to custody evaluations, parenting assessments, adoption studies, reports to the court, risk assessments for sexual offenses, educational classes for Driving Under the Influence (DUI)/Driving While Intoxicated (DWI) competency evaluations
• For purposes of insurance
• To get or keep a license

All charges

All charges

• 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 https://brightfutures.aap.org
• Children’s immunizations endorsed by the Centers for Disease Control (CDC) including DTaP/Tdap, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the website at www.cdc.gov/vaccines/schedules/index.html
• You may also find a complete list of U.S. Preventive Services Task Force (USPSTF) A and B recommendations online at 
  https://www.uspreventiveservicestaskforce.org/uspstf/recommendation-topics/uspstf-a-and-b-recommendations.

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

Nothing

In-Network: Nothing

Out-of-Network: 40% of charges after out-of-network deductible

Obesity counseling, screening and referral for those persons at or above the USPSTF obesity prevention risk factor level, 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, including weight management classes and individual and group behavior counseling sessions as described in our Coverage Criteria available at www.healthpartners.com/public/coverage-criteria/.
• Family centered programs when medically identified to support obesity prevention and management by an in-network provider. This includes group counseling, diabetes education/classes, nutrition education/classes, community health workers, diabetes prevention and weight management as described in our Coverage Criteria available at www.healthpartners.com/public/coverage-criteria/.

Notes: Also see Section 5(h) for additional nutritional and physical activity support

• When anti-obesity medication is prescribed as indicated by the FDA obesity medication treatment guidelines. See Section 5(f) for cost share requirements for anti-obesity medications.
• When Bariatric or Metabolic surgical treatment or intervention is indicated for severe obesity. See Section 5(b) for surgery requirements and cost share.

Nothing

In-Network: Nothing

Out-of-Network: 40% of charges after out-of-network deductible

We cover complete maternity (obstetrical) care, such as:

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

Nothing for routine prenatal care, the first postpartum care visit or routine gestational diabetes screening. $45 per office visit for postpartum care visits thereafter.

In-Network: Nothing.

Out-of-Network: 40% of charges after out-of-network deductible

• Delivery

Note: Here are some things to keep in mind:

• You do not need to prior authorize your vaginal delivery.
• As part of your coverage, you have access to in-network certified nurse midwives, home nurse visits and board-certified lactation specialists during the prenatal and post-partum period.
• 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 and other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment.
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• We pay non-routine prenatal and postnatal care the same as for illness and injury.

Note: When a newborn requires non-routine 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.

$500 hospital deductible for inpatient and outpatient hospital services combined, then Nothing for inpatient hospital maternity charges

In-Network: $1,500 copayment for inpatient hospital maternity services, then Nothing for inpatient hospital charges

Out-of-Network: 40% of charges after out-of-network deductible

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

Nothing

In-Network: Nothing

Out-of-Network: 40% of charges after out-of-network deductible

Contraceptive counseling

Nothing

In-Network: Nothing

Out-of-Network: 40% of the charges after out-of-network deductible

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

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

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

Note: Your plan offers 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).

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

Nothing

In-Network: Nothing

Out-of-Network: 40% of charges after out-of-network deductible

Voluntary male sterilization 

$45 per office visit

$500 hospital deductible for inpatient and outpatient hospital services combined, then 20% of charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

Not covered:

• Reversal of voluntary surgical sterilization

All charges

All charges

We cover advance care planning in an office

Nothing

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

If you meet our criteria for coverage, you may qualify for our Medication Therapy Disease Management Program. The program covers consultations with a designated pharmacist.

Nothing

In-Network: Nothing

Out-of-Network: All charges

We cover diagnosis of infertility

In- or Out-of-Network: 20% of charges

In- or Out-of-Network: 20% of charges after in-network deductible

We cover fertility treatment including:

• Artificial insemination (AI)
  • Intravaginal insemination (IVI)
  • Intracervical insemination (ICI)
  • Intrauterine insemination (IUI)

Coverage is available with or without a diagnosis of infertility.

20% of charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

We cover fertility drugs

• Limited to products listed on the Formulary
• Fertility drugs used with IVF are limited to three cycles per calendar year

40% of charges

In-Network: 40% of charges after in-network deductible

Out-of-Network: All charges

We cover therapeutic preservation fertility services:

These preservation services are for members that may become infertile due to chemotherapy, pelvic radiotherapy, other gonadotoxic therapies, or ovary or testicle removal for treatment of disease. This includes fertility services associated with gender affirming care.

• Cryopreservation of sperm, oocyte, and embryo
• Sperm, oocyte and embryo storage for up to one year
• Thawing of preserved sperm, oocyte, and embryo

20% of charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: All charges

Not covered:

• 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 or egg
• Cost of storage of donor sperm, ova or embryo, except for therapeutic preservation services
• Fertility treatment after reversal of sterilization
• Artificial insemination for surrogate pregnancy

All charges

All charges

We cover:

• Testing and treatment
• Allergy injections and serum

$45 per office visit

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

Not covered:

• Provocative food testing
• Sublingual allergy desensitization

All charges

All charges

We cover:

• Chemotherapy
• Intravenous (IV)/Infusion therapy

For services received in an office or outpatient hospital: 15% of charges

Inpatient hospital services: $500 hospital deductible for inpatient and outpatient hospital services combined, then 20% of charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

• Radiation therapy
• Dialysis – hemodialysis and peritoneal dialysis
• Respiratory and inhalation therapy

Note: Cardiac rehabilitation following a qualifying event/ condition is covered under Physical and occupational therapies on page (Applies to printed brochure only).

For services received in an office or outpatient hospital: $45 per visit

Inpatient hospital services: $500 hospital deductible for inpatient and outpatient hospital services combined, then 20% of charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

We cover Applied Behavior Therapy (ABA) and Intensive Early Intervention Behavioral Therapy (IEIBT) for the treatment of Autism Spectrum Disorder.

$45 per visit

In-Network: 20% of charges after in-network deductible

Out-of-Network: All charges

• Specialty drugs

We cover specialty drugs that are used to treat chronic health conditions including but not limited to such conditions as transplant recipients, immunological conditions, growth hormone, bleeding disorder, HIV/AIDS. We require prior authorization for certain drugs and the site where the drug will be administered.

40% of charges

In-Network: 40% of charges, after deductible

Out-of-Network: All charges

Growth hormone therapy (GHT)

Note: Growth hormone is covered under the prescription drug benefit. See Services requiring our prior approval in Section 3.
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 (Applies to printed brochure only).

20% of charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

Not covered: Growth hormones which are not for growth hormone deficiency or chronic renal insufficiency

All charges

All charges

We cover gene therapy treatment that meets our current medical coverage criteria. Gene therapy must be provided by a designated provider. Specific types of gene therapy are limited to therapies and conditions specified in our medical coverage criteria.

For services received in an office: $45 per visit

For services received in a hospital: $500 hospital deductible for inpatient and outpatient hospital services combined, then 20% of charges

For services received in the home: 20% of the charges incurred

In-Network: 20% of charges after in-network deductible

Out-of-Network: All charges

We cover:

• Rehabilitative therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or injury. You must achieve significant functional improvement, within a predictable period of time (generally within a period of two months), toward your maximum potential ability to perform functional daily living activities.
• Habilitative care rendered for congenital, developmental or medical conditions which have significantly limited the successful initiation of normal speech and motor development.

Note: To be considered habilitative, significant functional improvement and measurable progress must be made toward achieving functional goals and your maximum potential ability, within a predictable period of time. Our Plan Medical Director will determine whether measurable progress has been made based on objective documentation.

For services received in an office or outpatient hospital: $45 per visit

Inpatient hospital services: $500 hospital deductible for inpatient and outpatient hospital services combined, then 20% of charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

• Cardiac rehabilitation following a qualifying event/condition is provided for Phase I and Phase II if it is medically necessary. Phase III and IV are not covered.

$45 per office visit

Nothing for inpatient or outpatient hospital

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

Not covered:

• Long-term rehabilitative therapy (maintenance care)
• Health club memberships, exercise programs and use or purchase of exercise equipment

All charges

All charges

We cover:

• Speech therapy for congenital, developmental or medical conditions which have significantly limited the successful initiation of normal speech development.
• Usually 60 visits or two months per condition per year

For services received in an office or outpatient hospital: $45 per visit

Inpatient hospital services: $500 hospital deductible for inpatient and outpatient hospital services combined, then 20% of charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

Not covered: Long term rehabilitative therapy (maintenance care)

All charges

All charges

We cover:

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

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

Nothing

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

• External hearing aids for members age 18 or younger who have hearing loss that is not correctable by other covered procedures. Coverage is limited to one basic, standard hearing aid for each ear every three years. A basic hearing aid is defined as a hearing device that consists of a microphone, amplifier, volume control, battery and receiver. It does not include upgrades above and beyond the functionality of a basic hearing aid, including but not limited to hearing improvements for group settings, background noise, Bluetooth/remote control functionality, or extended warranties.
• Implanted hearing related devices, such as bone- anchored hearing aids (BAHA) and cochlear implants based on our criteria.

20% of the charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

Not covered:

• Charges for upgrades above the cost of a basic, standard hearing aid
• Hearing aids, testing and examinations for them, unless noted above

All charges

All charges

• Hearing Aids

The plan covers up to two TruHearing-branded hearing aids every year (one per ear per year). This benefit is limited to TruHearing Advanced and Premium hearing aids, which come in various styles and colors. Premium hearing aids are available in rechargeable style options for an additional $75 per aid. You must see a TruHearing provider to use this benefit. TruHearing offers a national network of providers. Call 833-718-5803 to schedule an appointment (for TTY, dial 711).

Hearing aid purchase includes:

• 3 provider visits within the first year of hearing aid purchase
• 45-day trial period
• 3-year extended warranty
• 48 batteries per aid for non-rechargeable models

This benefit does not include or cover any of the following:

• Additional cost for optional hearing aid rechargeability
• Ear molds
• Hearing aid accessories
• Additional provider visits
• Additional batteries or batteries when a rechargeable hearing aid is purchased
• Hearing aids that are not TruHearing-branded hearing aids
• Costs associated with loss and damage warranty claims

Costs associated with excluded items are the responsibility of the enrollee and not covered by the plan.

$699 copayment per aid for Advanced Aids*

$999 copayment per aid for Premium Aids*

A rechargeable battery option is available on some Premium hearing aids for an additional $75 per aid.

*Please note that this service does not apply to your maximum out-of-pocket amount for medical services.

All charges

We cover:

• Eye exams to determine the need for vision correction
• Annual eye refractions

Note: See Preventive care, adult; Preventive care, children

Nothing

In-Network: Nothing

Out-of-Network: 40% of charges after out-of-network deductible

• Diagnosis and treatment of illness and injury to the eye

$45 per office visit

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

Initial evaluation, lenses and fitting for contact or eyeglass lenses if medically necessary for the post surgical treatment of cataracts or for the treatment of aphakia, acute or chronic corneal pathology, or keratoconus

$45 per office visit

All charges for lens replacement beyond the initial pair

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

All charges for lens replacement beyond the initial pair

Not covered:

• Eyeglasses or contact lenses and their fitting, measurement and adjustment, except as shown above
• Eyewear options, including, but not limited to, ultraviolet absorbing properties, scratch resistant protective coating, sunglasses in addition to other lenses, anti-reflective coating, edge treatment, fashion tints or polarized lenses, frames, contact lens cleaning solution or normal saline for contact lenses, progressive lenses or invisible bifocals, low vision aids or oversize lenses
• Eye exercises and orthoptics
• Vision correction (refractive) surgeries in otherwise healthy eyes to replace eyeglasses or contact lenses. Examples include, but are not limited to, LASIK, radial keratotomy, laser and other refractive eye surgery

All charges

All charges

We cover routine foot care when you are under active treatment for a metabolic or peripheral vascular disease, such as diabetes

$45 per office visit

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

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

We cover:

• Artificial limbs
• Artificial eye (ocular prosthesis), including polishing and adjustments
• Prosthetic sleeve or sock
• Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy
• Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome
• Orthopedic and corrective shoes when approved by this Plan based on our criteria
• Replacement or repair of DME or orthotics is covered to accommodate growth requirements or if needed due to a change in a medical condition which affects the fit or function of the item
• Hearing aids and implantable hearing-related devices as described under Hearing Services on page (Applies to printed brochure only).

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.

Coverage is limited to one prosthetic item unless bilateral prostheses are recommended and are Medically Necessary for both sides

20% of charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

• Wigs required due to hair loss caused by alopecia areata

20% of charges, and all charges beyond one wig per calendar year limit

In-Network: 20% of charges after in-network deductible, and all charges beyond one wig per calendar year limit

Out-of-Network: 40% of charges after out-of-network deductible, and all charges beyond one wig per calendar year limit

Not covered:

• Over-the-counter foot orthotics
• Non-custom orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and heel cups
• Replacement or repair of any covered items if they are damaged or destroyed by member misuse, abuse or carelessness; lost; or stolen
• Duplicate or similar items, including replacement or repair of duplicate or similar items
• Items which are primarily educational in nature or for hygiene, vocation, comfort, convenience, recreation or safety
• Other equipment and supplies, including but not limited to assistive devices, that we determine are not eligible for coverage

All charges

All charges

We cover rental or purchase of durable medical equipment, at our option, including repair and adjustment, when prescribed by your Plan physician. Covered items include:

• Oxygen
• Dialysis equipment
• Hospital beds
• Wheelchairs
• Crutches
• Walkers
• Blood glucose monitors
• Insulin pumps
• Diabetic supplies
• Disposable needles and syringes needed for the administration of covered medications
• Compression garments

Note: Covered items may be subject to limitations or require prior authorization. We reserve the right to determine if an item will be approved for rental vs. purchase.

20% of charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

Specialty dietary treatment for phenylketonuria (PKU)

No more than a 90-day supply of special dietary treatment for phenylketonuria is covered and dispensed at a time.

20% of charges

In-Network: 20% of charges

Out-of-Network: 40% of charges after out-of-network deductible

Not covered:

• Replacement or repair of any covered items if they are damaged or destroyed by member misuse, abuse or carelessness; lost; or stolen
• Duplicate or similar items
• Items which are primarily educational in nature or for hygiene, vocation, comfort, convenience or recreation
• Household equipment, such as exercise cycles, air purifiers, water purifiers, air conditioners, non-allergenic pillows, mattresses or water beds
• Household fixtures, such as escalators or elevators, ramps, swimming pools or saunas
• Modifications to the home, such as wiring, plumbing or charges to install equipment
• Vehicle, car or van modifications, such as hand brakes, hydraulic lifts and car carriers
• Rental of medically necessary durable medical equipment while your own equipment is being repaired, that is beyond one month rental
• Other equipment and supplies, including but not limited to assistive devices, that we determine are not eligible for coverage
• We require that certain diabetic supplies and equipment be purchased at a pharmacy

All charges

All charges

We cover home healthcare ordered by a Plan physician and provided by a registered nurse (R.N.), licensed practical nurse (L.P.N.), or home health aide, as shown below. You need to be homebound (i.e., unable to leave home without considerable effort due to a medical condition) to receive home health services. You do not need to be homebound to receive total parenteral nutrition/intravenous ("TPN/IV") therapy.

• At home physical therapy, occupational therapy, speech therapy, respiratory therapy and home health aide services

$45 per visit

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

• TPN/intravenous therapy (other than specialty drugs described below), skilled nursing services, nonroutine prenatal and postnatal services, and phototherapy

20% of charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

• Specialty drugs administered in home

We cover specialty drugs that are used to treat chronic health conditions including but not limited to such conditions as transplant recipients, immunological conditions, growth hormone, bleeding disorder, HIV/AIDS. We require prior authorization for certain drugs and the site where the drug will be administered.

40% of charges

In-Network: 40% of charges, after deductible

Out-of-Network: All charges

• Palliative care

Palliative care includes symptom management, education and establishing goals of care.

If you are eligible to receive palliative care in the home and you are not homebound, there is a maximum of 12 visits per calendar year. Additional palliative care visits are eligible under the home health services benefit if you are homebound and meet all other requirements defined in this section.

Note: We waive the requirement that you be homebound if you have a serious illness or life-limiting condition.

$45 per visit

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

• Routine prenatal and postnatal services and child health services

Nothing

In-Network: Nothing

Out-of-Network: 40% of charges after out-of-network 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

We cover chiropractic services for rehabilitative care, provided to diagnose and treat neuromusculoskeletal conditions, limited to:

• Manipulation of the spine
• Adjunctive procedures such as massage therapy, ultrasound, electrical muscle stimulation, and vibratory therapy, when they are performed in conjunction with other treatment by a chiropractor, are part of a prescribed treatment plan and are not billed separately

$45 per office visit

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

Not covered:

• Massage therapy as a standalone treatment
• Naturopathic services
• Hypnotherapy

All charges

All charges

We cover:

• Acupuncture
• Biofeedback for:
  • incontinence
  • headaches
  • musculo-skeletal spasms which do not respond to other treatments
  • mental/nervous disorders

$45 per office visit

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

Not covered:

• Naturopathic services
• Hypnotherapy

All charges

All charges

We cover:

• Education for preventive services
• Tobacco cessation programs, including individual, group, phone counseling, and physician prescribed over-the-counter (OTC) and prescription drugs approved by the FDA to treat nicotine dependence. Includes up to two quit attempts and up to four counseling sessions
• Physician prescribed over-the-counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence whether or not one is enrolled in a smoking cessation program
• Education for the management of chronic health problems (such as diabetes)

Nothing

In-Network: Nothing

Out-of-Network: 40% of charges after out-of-network deductible

We cover a comprehensive range of services, such as:

• Operative procedures, including normal pre- and post-operative care by the surgeon
• Treatment of fractures, including casting
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery)
• Treatment of burns
• Gender confirmation surgery that meets medical coverage criteria
• Insertion of internal prosthetic devices.
  See 5(a) -- Orthopedic and prosthetic devices for device coverage information

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.

$45 per office visit

$500 hospital deductible for inpatient and outpatient hospital services combined, then 20% of charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

Surgical treatment of severe obesity (bariatric surgery)

See Services requiring our prior approval on page (Applies to printed brochure only). See bariatric surgery criteria available at www.healthpartners.com/public/coverage-criteria/

$45 per office visit

$500 hospital deductible for inpatient and outpatient hospital services combined, then 20% of charges.

In-Network: 20% of charges after in-network deductible

Out-of-Network: All charges

Not covered:

• Reversal of voluntary sterilization

All charges

All charges

We cover:

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

Note: Port wine stains do not have to result in a functional defect to be covered.

• 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 (confirmation) surgery that meets medical coverage criteria, including breast augmentation, mastectomy, reduction mammoplasty, orchidectomy, penectomy, urethroplasty, vaginoplasty, labiaplasty, clitoroplasty, hysterectomy, salpingectomy, oophorectomy, vaginectomy and phalloplasty or metoidioplasty, scrotoplasty, and placement of a testicular prosthesis and erectile prosthesis. Prior authorization is required.

$45 per office visit

$500 hospital deductible for inpatient and outpatient hospital services combined, then 20% of charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

Not covered:

• Surgery, services, treatments or drugs that improve or enhance the shape or appearance of the body for purposes other than treating an illness or injury. These types of services are considered cosmetic and are not covered whether or not they also impact your psychological/emotional well-being or self-esteem. Examples include but are not limited to enhancement procedures, reduction procedures and scar revision surgery. This exclusion does not apply to services for port wine stain removal, reconstructive surgery, gender confirmation services and emergency care required due to complications of Cosmetic Surgery.

All charges

All charges

We cover oral surgical procedures, limited to:

• Reduction of fractures of the jaws or facial bones
• Surgical correction of cleft lip, cleft palate
• Removal of stones from salivary ducts
• Excision of leukoplakia or malignancies
• Excision of cysts and incision of abscesses when done as independent procedures
• Other surgical procedures that do not involve the teeth or their supporting structures, including non-dental treatment of temporomandibular joint dysfunction (TMJ)

$45 per office visit

$500 hospital deductible for inpatient and outpatient hospital services combined, then 20% of charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

We cover orthognathic surgery for the treatment of a skeletal malocclusion when a functional occlusion cannot be achieved through non-surgical treatment alone and a demonstrable functional impairment exists.

25% of charges

In-Network: 25% of charges after in-network deductible

Out-of-Network: 50% of charges after out-of-network deductible

Not covered:

• Oral implants and transplants
• Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva and alveolar bone)
• Orthodontic services (pre or post operative) associated with orthognathic surgery

All charges

All charges

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

$500 hospital deductible for inpatient and outpatient hospital services combined, then 20% of charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

These tandem blood or marrow stem cell transplants for covered transplants are not 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)

$500 hospital deductible for inpatient and outpatient hospital services combined, then 20% of charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

These blood or marrow stem cell transplants are not subject to medical necessity and experimental investigational review by the Plan. Refer to Other services in Section 3 for prior authorization procedures.

Physicians consider many features to determine how diseases will respond to different types of treatment. Some of the features measured are the presence or absence of normal and abnormal chromosomes, the extension of the disease throughout the body, and how fast the tumor cells grow. By analyzing these and other characteristics, physicians can determine which diseases will respond to treatment without transplant and which diseases may respond to transplant.

The Plan extends coverage for the diagnosis 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 non-Hodgkin’s lymphoma with recurrence (relapsed)
• Amyloidosis
• Chronic lymphocytic leukemia/small lymphocytic lymphoma (CLL/SLL)
• Hemoglobinopathy
• Hurler’s syndrome, Maroteaux-Lamy syndrome
• 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)
• 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)
• AL Amyloidosis
• Breast Cancer
• Epithelial ovarian cancer
• Multiple myeloma
• Neuroblastoma
• Recurrent germ cell tumors (including testicular, mediastinal, retroperitoneal)

$500 hospital deductible for inpatient and outpatient hospital services combined, then 20% of charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network 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)
• Chronic myelogenous leukemia
• Hemoglobinopathy
• Marrow failure and related disorders (i.e., Fanconi’s, Paroxysmal Nocturnal Hemoglobinuria, 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

$500 hospital deductible for inpatient and outpatient hospital services combined, then 20% of charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network 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.

$500 hospital deductible for inpatient and outpatient hospital services combined, then 20% of charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

Allogeneic transplants for

• Early stage (indolent or non-advanced) small cell lymphocytic lymphoma
• Sickle cell anemia

Autologous transplants for

• Advanced childhood kidney cancers
• Advanced Ewing sarcoma
• Childhood rhabdomyosarcoma
• Mantle cell (Non-Hodgkin lymphoma)

$500 hospital deductible for inpatient and outpatient hospital services combined, then 20% of charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

HealthPartners Designated Transplant Providers and HealthPartners Centers of Excellence - These are local and national Designated Transplant Centers based upon their experience, clinical outcomes, service, access, cost, coordination of care, research and education. For a list of participating programs visit www.healthpartners.com/pshb.

Transplant procedures must be performed at HealthPartners Designated Transplant Centers

In-Network: transplant procedures must be performed at HealthPartners Designated Transplant Centers to receive in-network benefits

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

$500 hospital deductible for inpatient and outpatient hospital services combined, then 20% of charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network 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

We cover professional services provided in –

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

$500 hospital deductible for inpatient and outpatient hospital services combined, then 20% of charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

We cover professional services provided in an office

$45 per office visit

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

We may provide travel and lodging when an enrollee needs a transplant or CAR-T therapy and a designated transplant center or CAR-T treatment center is greater than 100 miles from the enrollee’s primary address.

To receive reimbursement for eligible travel and lodging expenses, the Insured will need to submit a Travel Benefit Claim Form, including receipts of services. Log on to your account at www.healthpartners.com/pshb or call Member Services to access the Travel Benefit Claim Form or to determine if additional Coverage Criteria Policies apply.

20% of charges

Expenses for travel, and lodging for the enrollee (the recipient) and one adult companion, or up to two companions for a recipient that is a minor dependent, may be covered, up to a maximum of $10,000 per transplant or CAR-T therapy. Lodging coverage is limited to $100 per day.

20% of charges

Expenses for travel, and lodging for the enrollee (the recipient) and one adult companion may be covered, up to a maximum of $10,000 per transplant or CAR-T therapy. Commercial lodging reimbursement (as may be adjusted by IRS rules) is limited to a maximum of $50 per night if the Insured travels alone or a maximum of $100 per night if the Insured travels with a companion.

Out-of-Network: All Charges

We cover room and board, such as

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

For Maternity Care see page (Applies to printed brochure only).

Note: If you want a private room when it is not medically necessary, you pay the additional charge above the semiprivate room rate.

$500 hospital deductible for inpatient and outpatient hospital services combined, then 20% of charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

We cover other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and X-rays
• Administration of blood and blood products
• Blood or blood plasma (unless replaced) and blood derivatives
• 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
• MRI / CT scans

$500 hospital deductible for inpatient and outpatient hospital services combined, then 20% of charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

Not covered:

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

All charges

All charges

We cover:

• 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
• Pre-surgical testing
• Dressings, casts and sterile tray services
• Medical supplies, including oxygen
• Anesthetics and anesthesia service
• MRI / CT scans

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.

$500 hospital deductible for inpatient and outpatient hospital services combined, then 20% of charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

• Blood and blood plasma (unless replaced) and blood derivatives

15% of charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

• Specialty drugs

We cover specialty drugs that are used to treat chronic health conditions including but not limited to such conditions as transplant recipients, immunological conditions, growth hormone, bleeding disorder, HIV/AIDS. We require prior authorization for certain drugs and the site where the drug will be administered.

40% of charges

In-Network: 40% of charges, after in-network deductible

Out-of-Network: All charges

We cover a comprehensive range of benefits for up to 120 days per calendar year when full-time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by your Plan doctor and prior authorized by this Plan. All necessary services are covered, including:

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

$500 hospital deductible for inpatient and outpatient hospital services combined, then 20% of charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

Not covered: Custodial care

All charges

All charges

We cover supportive and palliative care in your home or a hospice if you are terminally ill. We cover the following services:

• Outpatient care, family counseling and continuous care
• Inpatient care, when medically necessary
• Respite care
• End of life care

Note: Respite care is limited to 5 days per episode, and respite care and continuous care combined are limited to 30 days.

Note: Inpatient hospital care: designed for those patients who require an acute hospital admission for pain or symptom control related to the terminal illness. Free-standing hospice: a hospice inpatient unit set up as a geographically distinct building. Residential hospices/hospice houses: goal is to provide longer-term care, in homelike settings, for patients who cannot be cared for in their own homes. Staffing and intensity of services are comparable to a board-and-care home or other types of licensed residential facility. A residential hospice program may be operated by a home care hospice or by an independent agency that contracts with a community hospice for professional services. Payment for residential room and board is made privately.

Nothing

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

Not covered:

• Independent nursing, homemaker services
• Room and board expenses in a residential hospice facility, free standing hospice or skilled nursing facility

All charges

All charges

Ambulance and medical transportation for medical emergencies described in Section 5(d) and non-emergency medical transportation when medically appropriate.

The amount you pay for air ambulance services will be determined based on the requirements of the No Surprises Act and its implementing regulations.

In- or Out-of-Network: 20% of charges

In- or Out-of-Network: 20% of charges after in-network deductible

Note: Fixed Wing Air Ambulance transport requires prior authorization from HealthPartners. Fixed Wing Air Ambulance is an aircraft such as an airplane, jet, or turbo prop plan that is able to travel longer distances than its counterpart, the Rotary Wing Air Ambulance (i.e. the helicopter). Under the No Surprises Act, Non-Network air ambulance providers may not bill patients for more than their cost-sharing responsibility for the corresponding Network service.

We cover:

• Emergency and urgently needed services at a doctor’s office
• Emergency and urgently needed services at an urgent care clinic

If other services are performed during the visit, such as diagnostic imaging or laboratory services, additional Deductible, Copayment or Coinsurance may apply. Diagnostic imaging services and laboratory services are covered under the "Lab, X-ray and other diagnostic tests" section.

$45 per office visit

$0 for the first 5 office, convenience clinic, telephone, urgent care visits, evisits and video visits combined in a calendar year (deductible does not apply), then 20% of charges, subject to the in-network deductible. Physician’s services, laboratory and radiology performed in conjunction with the same visit and on the same date of service are included; however, charges for day treatment services, group visits, office procedures and other ancillary services are not included and will be subject to your deductible and coinsurance.

• Emergency and urgently needed services as an outpatient in a hospital, including doctors' services

The amount you pay for these services will be determined based on the requirements of the No Surprises Act and its implementing regulations.

$250 per visit

The ER copayment is waived if you are admitted to the hospital

20% of charges after in-network deductible

• Emergency and urgently needed inpatient hospital services

The amount you pay for these services will be determined based on the requirements of the No Surprises Act and its implementing regulations.

$500 hospital deductible for inpatient and outpatient hospital services combined, then 20% of charges

20% of charges after in-network deductible

Ambulance and medical transportation for medical emergencies described in this section and non-emergency medical transportation when medically appropriate.

The amount you pay for air ambulance services will be determined based on the requirements of the No Surprises Act and its implementing regulations.

Under the No Surprises Act, out-of-network air ambulance providers may not bill patients for more than their cost-sharing responsibility for the corresponding in-network service.

In- or Out-of-Network: 20% of charges

In- or Out-of-Network: 20% of charges after in-network deductible

Note: Fixed Wing Air Ambulance transport requires prior authorization from HealthPartners. Fixed Wing Air Ambulance is an aircraft such as an airplane, jet, or turbo prop plan that is able to travel longer distances than its counterpart, the Rotary Wing Air Ambulance (i.e. the helicopter). Under the No Surprises Act, Non-Network air ambulance providers may not bill patients for more than their cost-sharing responsibility for the corresponding Network service.

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

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

We cover 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 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
• Gender affirming care for gender dysphoria

$45 per visit

In-Network: $0 for the first 5 office, convenience clinic, telephone, urgent care visits, evisits and video visits combined in a calendar year (deductible does not apply), then 20% of charges, subject to the in-network deductible. Physician’s services, laboratory and radiology performed in conjunction with the same visit and on the same date of service are included; however, charges for day treatment services, group visits, office procedures and other ancillary services are not included and will be subject to your deductible and coinsurance.

Out-of-Network: 40% of charges after out-of-network deductible

Group therapy visits for mental health

$22.50 per visit

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

We cover:

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

$45 per visit

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

We cover 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, residential treatment, and other hospital services

$500 hospital deductible for inpatient and outpatient hospital services combined, then 20% of inpatient hospital charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

We cover outpatient services provided and billed by a hospital or other covered facility

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

$45 per visit

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

• Marriage or relationship counseling services
• Sex therapy
• Religious counseling
• Wilderness and outdoor programs even when the program is through a licensed facility
• Animal therapy, including hippotherapy and equine therapy
• Professional services associated with substance use disorder interventions. A “substance use disorder intervention” is a gathering of family and/or friends to encourage an Enrollee or family member to seek substance use disorder treatment.

All charges

All charges

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

• Drugs and medications that by Federal law of the United States require a physician's prescription for their purchase, except those listed as Not covered.
• Insulin
• Gender affirming drugs. Preferred outpatient products and any authorization requirements are noted in the Drug Formulary.
• Medications prescribed to treat obesity

Authorization requirements are noted in the Drug Formulary

$5 for low cost generic formulary drugs

$25 for high cost generic formulary drugs

$75 for preferred brand-name formulary drugs

40% coinsurance for non-preferred brand-name formulary drugs

The copayment applies per 30-day supply, or portion thereof

In-Network:

$5 for low cost generic formulary drugs (deductible does not apply)

$25 for high cost generic formulary drugs (deductible does not apply)

$75 for preferred brand-name formulary drugs after in-network deductible

40% coinsurance for non-preferred brand-name formulary drugs after in-network deductible

The copayment applies per 30-day supply, or portion thereof

Out-of-Network: 40% of charges after out-of-network deductible

We cover all FDA approved contraceptive methods as listed in the Health Resources and Services Administration site https://www.hrsa.gov/womens-guidelines, including over-the-counter and prescription drugs approved by the FDA to prevent unintended pregnancy. 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. Your prescriber will obtain prior approval. Contact Member Services at 844-440-1900 (TTY: 711) for information on this process.

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)

Notes:

• Coverage is limited to females (based on sex assigned at birth)
• This benefit applies whether the birth control drug or device is used for birth control or for a medically necessary purpose other than birth control.
• Over-the-counter contraceptive drugs and devices approved by the FDA require a written prescription by an approved provider. These may be purchased at a pharmacy counter.

Nothing for formulary drugs

Nothing if a Provider requests that a Non-Formulary contraceptive drug be dispensed as written

In-Network: Nothing for formulary drugs; Nothing if a Provider requests that a Non-Formulary contraceptive drug be dispensed as written

Out-of-Network: 40% of charges after out-of-network deductible

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

Opioid rescue agents, such as naloxone nasal sprays are covered under this Plan. Generic nasal spray (4 mg) is covered with no cost sharing when obtained from a network pharmacy.

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

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

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

Nothing

In-Network: Nothing

Out-of-Network: 40% of charges after out-of-network deductible

Diabetic supplies limited to

• disposable needles and syringes for the administration of covered medications
• blood glucose testing meters and strips
• other diabetes supplies such as lancets and pen needles or insulin syringes

20% of charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

Drugs for breast cancer prevention for individuals at high risk for breast cancer who have not yet been diagnosed with the disease

Nothing for formulary drugs

In-Network: Nothing for formulary drugs

Out-of-Network: 40% of charges after out-of-network deductible

We cover specialty drugs.

Note: Specialty drugs are injectable and oral medications that are used to treat chronic health conditions including but not limited to such conditions as transplant recipients, immunological conditions, growth hormone, bleeding disorder, HIV/AIDS. We require prior authorization for certain drugs and the site where the drug will be administered. Please refer to the drug plan formulary to determine if the drug you have been prescribed by your physician needs to be filled by one of the plan's Specialty Pharmacy providers.

• For safety, all mailing will be shipped based on temperature requirements and considerations.
• Specialty drugs cannot be obtained through the traditional 90-day mail order program.

40% coinsurance for specialty drugs

In-Network: 40% coinsurance for specialty drugs, after in-network deductible

Out-of-Network: All charges

We cover oral chemotherapy drugs.

Note: oral chemotherapy drugs must be obtained from a designated vendor

40% coinsurance for formulary drugs

In-Network: 40% coinsurance for formulary drugs, after in-network deductible

Out-of-Network: All charges

Not covered:

• Drugs and supplies for cosmetic purposes
• Nonprescription (over-the counter) drugs, including, but not limited to vitamins, nutrients, medical foods, food supplements and homeopathic remedies, even if a physician prescribes or administers them, except as specified in this brochure or on the Formulary and prescribed by a physician or legally authorized health care provider under applicable state and federal law.
• Non-Formulary Drugs, unless a Formulary exception has been granted through the Formulary exception process
• Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies (High Option only)
• Medical supplies such as dressings and antiseptics
• Drugs to enhance athletic performance
• Sexual dysfunction drugs
• Replacement of prescription drugs, equipment and supplies due to loss, damage or theft
• Medical cannabis
• Drugs that are newly approved by the FDA until they are reviewed and coverage is established by HealthPartners Pharmacy and Therapeutics Committee.
• Drugs on the Excluded Drug List. The Excluded Drug List includes select drugs within a therapy class that are not eligible for coverage. This includes drugs that may be excluded for certain indications. The Excluded Drug List is available at www.healthpartners.com/pshb

All charges

All charges

You may also get outpatient formulary prescription drugs which can be self-administered through the designated mail order service. For information on how to obtain drugs through HealthPartners mail order service, please visit www.healthpartners.com/pshb.

This benefit does not apply to drugs listed under Limited Benefits below.

$10 for low cost generic formulary drugs

$50 for high cost generic formulary drugs

$150 for preferred brand-name formulary drugs

40% coinsurance for non-preferred brand-name formulary drugs

The copayment applies per 90-day supply, or portion thereof

In-Network:

$10 for low cost generic formulary drugs (deductible does not apply)

$50 for high cost generic formulary drugs (deductible does not apply)

$150 for preferred brand-name formulary drugs after in-network deductible

40% coinsurance for non-preferred brand-name formulary drugs after in-network deductible

The copayment applies per 90-day supply, or portion thereof

Out-of-Network: all charges

Growth hormones

20% of charges

In-Network: 20% of charges after in-network deductible

Out-of-Network: 40% of charges after out-of-network deductible

Fertility drugs

• Limited to products listed on the Formulary
• Fertility drugs used with IVF are limited to three cycles per calendar year

40% of charges

In-Network: 40% of charges after in-network deductible

Out-of-Network: All charges

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

• Drugs and medications that by Federal law of the United States require a physician's prescription for their purchase, except those listed as Not covered.
• Insulin
• Gender affirming drugs. Preferred outpatient products and any authorization requirements are noted in the Drug Formulary
• Specialty drugs. Specialty drugs are limited to a 30-day supply.
• Oral chemotherapy drugs
• Growth hormones
  

$5 for Tier 1 – Preferred Generic Formulary Drugs

$20 for Tier 2 – Generic Formulary Drugs

$47 for Tier 3 – Preferred Brand Formulary Drugs

40% coinsurance for Tier 4 – Non-preferred Formulary Drugs

33% coinsurance for Tier 5 – Specialty Formulary Drugs

The copayment applies per 30-day supply, or portion thereof

You pay no more than $35 per month supply of each covered insulin product, regardless of tier.

In-Network:

$5 for Tier 1 – Preferred Generic Formulary Drugs (deductible does not apply)

$20 for Tier 2 – Generic Formulary Drugs (deductible does not apply)

$47 for Tier 3 – Preferred Brand Formulary Drugs after $590 Part D deductible

40% coinsurance for Tier 4 – Non-preferred Formulary Drugs after $590 Part D deductible

25% coinsurance for Tier 5 – Specialty Formulary Drugs after $590 Part D deductible

The copayment applies per 30-day supply, or portion thereof

You pay no more than $35 per month supply of each covered insulin product, regardless of tier.

Out-of-Network:

Specialty drugs: all charges

All other formulary drugs: 40% of charges after PSHB out-of-network deductible

• Medications prescribed to treat obesity included in the Preferred Rx Drug Formulary

Authorization requirements are noted in the Preferred Rx Drug Formulary

Note: If you have Part D, see the Medicare Part D Prescription Drug Plan Evidence of Coverage document for information on what's covered under Part D and applies to the out-of-pocket threshold amount.

$5 for low cost generic formulary drugs

$25 for high cost generic formulary drugs

$75 for preferred brand-name formulary drugs

40% coinsurance for non-preferred brand-name formulary drugs

The copayment applies per 30-day supply, or portion thereof

In-Network:

$5 for low cost generic formulary drugs (deductible does not apply)

$25 for high cost generic formulary drugs (deductible does not apply)

$75 for preferred brand-name formulary drugs after PSHB in-network deductible

40% coinsurance for non-preferred brand-name formulary drugs after PSHB in-network deductible

The copayment applies per 30-day supply, or portion thereof

Out-of-Network: 40% of charges after PSHB out-of-network deductible

• Diabetic supplies included in the Preferred Rx Drug Formulary, limited to:

• disposable needles and syringes for the administration of covered medications
• blood glucose testing meters and strips
• other diabetes supplies such as lancets and pen needles or insulin syringes

Note: If you have Part D, see the Medicare Part D Prescription Drug Plan Evidence of Coverage document for information on what's covered under Part D and applies to the out-of-pocket threshold amount.

20% of charges

In-Network: 20% of charges after PSHB in-network deductible
Out-of-Network: 40% of charges after PSHB out-of-network deductible

• Special dietary treatment for PKU

20% of charges

In-Network: 20% of charges
Out-of-Network: 40% of charges after PSHB out-of-network deductible

• Oral amino acid based elemental formula

Note: If you have Part D, see the Medicare Part D Prescription Drug Plan Evidence of Coverage document for information on what's covered under Part D and applies to the out-of-pocket threshold amount.

20% of charges

In-Network: 20% of charges after PSHB in-network deductible
Out-of-Network: 40% of charges after PSHB out-of-network deductible

We cover all FDA approved contraceptive methods as listed in the Health Resources and Services Administration site https://www.hrsa.gov/womens-guidelines, including over-the-counter and prescription drugs approved by the FDA to prevent unintended pregnancy. 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. Your prescriber will obtain prior approval. Contact Member Services at 844-440-1900 (TTY: 711) for information on this process.

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)

Notes:

• Coverage is limited to females (based on sex assigned at birth)
• This benefit applies whether the birth control drug or device is used for birth control or for a medically necessary purpose other than birth control.

Over-the-counter contraceptive drugs and devices approved by the FDA require a written prescription by an approved provider. These may be purchased at a pharmacy counter.

Nothing for Preferred Rx formulary drugs

Nothing if a Provider requests that a Non-Formulary contraceptive drug be dispensed as written

In-Network: Nothing for Preferred Rx formulary drugs; Nothing if a Provider requests that a Non-Formulary contraceptive drug be dispensed as written

Out-of-Network: 40% of charges after PSHB out-of-network deductible

Not covered:

• Drugs and supplies for cosmetic purposes
• Nonprescription (over-the counter) drugs, including, but not limited to vitamins, nutrients, medical foods, food supplements and homeopathic remedies, even if a physician prescribes or administers them, except as specified in this brochure or on the Formulary and prescribed by a physician or legally authorized health care provider under applicable state and federal law.
• Non-Formulary Drugs, unless a Formulary exception has been granted through the Formulary exception process
• Drugs obtained at a non-Plan pharmacy; except for out- of-area emergencies (High Option only)
• Medical supplies such as dressings and antiseptics
• Drugs to enhance athletic performance
• Sexual dysfunction drugs
• Replacement of prescription drugs, equipment and supplies due to loss, damage or theft
• Medical cannabis
• Drugs that are newly approved by the FDA until they are reviewed and coverage is established by HealthPartners Pharmacy and Therapeutics Committee

All charges

All charges

You may also get outpatient formulary prescription drugs which can be self-administered through the designated mail order service. For information on how to obtain drugs through HealthPartners mail order service, please visit www.healthpartners.com/pshb.

Specialty drugs are limited to a 30-day supply and may not be available via mail order service.

Copayments apply per 90-day supply, or portion thereof

Mail-order pharmacy with preferred cost sharing:

$10 for Tier 1 – Preferred Generic Formulary Drugs

$40 for Tier 2 – Generic Formulary Drugs

$94 for Tier 3 – Preferred Brand Formulary Drugs

40% coinsurance for Tier 4 – Non-preferred Formulary Drugs

33% coinsurance for Tier 5 – Specialty Formulary Drugs

Mail-order pharmacy without preferred cost sharing:

$15 for Tier 1 – Preferred Generic Formulary Drugs

$60 for Tier 2 – Generic Formulary Drugs

$141 for Tier 3 – Preferred Brand Formulary Drugs

40% coinsurance for Tier 4 – Non-preferred Formulary Drugs

33% coinsurance for Tier 5 – Specialty Formulary Drugs

Mail-order pharmacy with preferred cost sharing:

$10 for Tier 1 – Preferred Generic Formulary Drugs (deductible does not apply)

$40 for Tier 2 – Generic Formulary Drugs (deductible does not apply)

$94 for Tier 3 – Preferred Brand Formulary Drugs after $590 Part D deductible

40% coinsurance for Tier 4 – Non-preferred Formulary Drugs after $590 Part D deductible

25% coinsurance for Tier 5 – Specialty Formulary Drugs, after $590 Part D deductible

Mail-order pharmacy without preferred cost sharing:

$15 for Tier 1 – Preferred Generic Formulary Drugs (deductible does not apply)

$60 for Tier 2 – Generic Formulary Drugs (deductible does not apply)

$141 for Tier 3 – Preferred Brand Formulary Drugs after $590 Part D deductible

40% coinsurance for Tier 4 – Non-preferred Formulary Drugs after $590 Part D deductible

25% coinsurance for Tier 5 – Specialty Formulary Drugs, after $590 Part D deductible

Out-of-Network: all charges

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

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

Nothing

In-Network: Nothing

Out-of-Network: 40% of charges after PSHB out-of-network deductible

Drugs for breast cancer prevention for individuals at high risk for breast cancer who have not yet been diagnosed with the disease as listed on the PSHB Preferred Rx formulary

Nothing

In-Network: Nothing

Out-of-Network: 40% of charges after PSHB out-of-network deductible

Opioid rescue agents, such as naloxone nasal sprays are covered under this Plan. Generic nasal spray (4 mg) is covered with no cost sharing when obtained from a network pharmacy.

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

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

Fertility drugs

• Limited to products listed on the Preferred Rx Drug Formulary
• Fertility drugs used with IVF are limited to three cycles per calendar year

Note: If you have Part D, see the Medicare Part D Prescription Drug Plan Evidence of Coverage document for information on what's covered under Part D and applies to the out-of-pocket threshold amount.

40% of charges

In-Network: 40% of charges after PSHB in-network deductible
Out-of-Network: All charges

We cover:

• Accidental dental services In-Network: Restorative services and supplies provided by Plan dentists necessary to promptly repair or replace sound, natural, unrestored teeth, including the cost and installation of necessary prescription dental prosthetic items or devices. The need for these services must directly result from an accidental injury, not including injury from biting, chewing, clenching or grinding of teeth. Coverage is limited to the initial treatment (or course of treatment) and/or restoration. Only services provided within 24 months from the date of injury are covered. When a dental implant is pursued, reimbursement for the implant and any associated procedures (including bone grafting, implant placement and restoration) is limited to the amount that would be paid toward the fabrication of a removable dental prosthesis. Full mouth rehabilitation to correct occlusion (bite) and malocclusion (misaligned teeth not due to the accident) are not covered.

20% of charges

20% of charges after in-network deductible

• Emergency accidental dental services Out-of-Network: Emergency dental services for accidental injury, as described above, when they are provided by Out-of-Network dentists if the injuries require immediate treatment.

30% of charges

30% of charges after in-network deductible

When you call the CareLine service, you reach a skilled nurse who is specially trained to assess medical conditions of all kinds. Call 612-339-3663 or 800-551-0859 and talk with a registered nurse who will discuss treatment options and answer your health questions.

If you’re an expecting or new parent and have questions after regular clinic hours, our BabyLine service is just for you. The BabyLine service is staffed by obstetric nurses who can help with questions relating to pregnancy, new baby care, nursing, and postpartum concerns. Call 612-333-BABY (333-2229) or 800-845-9297.

Our Behavioral Health Personalized Assistance Line (PAL) staff can match you with the network provider that best meets your behavioral health needs. We can identify providers based on:

• Specialty or subspecialty
• Specific diagnostic, language and cultural competence

And if you have an urgent need, we can link you to same day/next day psychiatric appointments. Call 952-883-5811 or 888-638-8787.

Nurse Navigators are experienced nurses who can help research treatment options, coordinate care and guide you through difficult decisions. Call 844-440-1900.

If you are deaf or hearing impaired, call 711

As a Plan member, you have instant access to detailed, secured information and helpful services tailored to you. Depending on your coverage, you may be able to:

• View your personal health record
• See your claims information
• View your benefits
• View your medical and dental provider networks
• Find health and wellness information
• Order new ID cards
• Make appointments at HealthPartners Clinics
• Refill a mail order prescription
• Determine the retail and mail order costs of specific drugs
• See all the medications on the HealthPartners preferred list of covered drugs
• Estimate your annual cost of medical care

To access your personalized member page, visit www.healthpartners.com/pshb.

Virtuwell is an online clinic that treats everyday illnesses so you- or your kids-can get better.

• Quickly and conveniently get care for over 60 common conditions
• get a diagnosis, treatment plan and prescription if needed- all in less than an hour
• you pay nothing. See section 5(a)
• 24/7, with nurse practitioners available

Download the HealthPartners app or visit the mobile site to find and manage your health plan on-the-go.

Use your smartphone to:

• Access your Member ID card
• Check your plan balances including your deductible
• Search for the closest care locations to you
• Get cost estimates
• View claims and Explanation of Benefits (EOBs)
• …and more

Download the app today in your app store or visit m.healthpartners.com to learn more about HealthPartners mobile offerings, visit www.healthpartners.com/gomobile.

If you have a mobile phone that can get text messages, you can receive a variety of texts from HealthPartners. Either opt in to receive weekly texts or add a phone number in your HealthPartners account to get text specific to you.

Text one of these commands to 77199:

• DED: For how much is remaining until you meet your deductible
• YUM: For better-for-you eating tips from yumPower
• FAMILY: For ideas to support your family's health
• QUITNOW: For tips to help you quit smoking

There’s no greater reward than living a healthy life. In case you need extra incentive, we've got one for you. When you complete your health assessment and register and complete an eligible online health improvement program, you are entitled to receive a contribution of $250 into your HealthPartners Wellness Account debit card to be used for most qualified medical expenses, prescriptions and IRS 213(d) vision expenses. For those with Self Plus One or Self and Family coverage, each adult employee or covered spouse, is eligible for the $250 contribution to the HealthPartners Wellness Account. We will send the policyholder two debit cards to access the account. Please keep your card for future use even if you use all of your health account dollars; you may be eligible for wellness incentives in subsequent benefit years. We do not send new cards to continuing participants until the card expires. The account funds must be used by December 31, 2026 or the account will be forfeited.

After completing the online health assessment, you may access online wellness courses to set personalized goals designed to improve your health through increased exercise, healthier nutrition habits, managing your weight, reduced stress, better emotional health, or goals that focus on managing a specific condition. You must complete the health assessment and complete an eligible online health improvement program no later than December 31, 2025 in order to receive these incentives.

Getting rewarded is simple.

• Log into your HealthPartners account at www.healthpartners.com/pshb. If you don't have a username and password, click on “Create an account”.
• Take your health assessment.
• Register for an eligible online health improvement program
• Complete the eligible online health improvement program.
• Don’t forget, this includes your covered spouse!
• One set of two debit cards will be sent to access the funds in your HealthPartners Wellness Account.

We offer many free programs that may help you with managing weight, dealing with stress, eating better, family health and more:

• Individual phone coaching with a professional health coach
• Group phone coaching with a professional health coach
• Online health programs

Sign in to your HealthPartners account at www.healthpartners.com/pshb for more information.

Start by taking an online assessment at healthpartners.com/pregnancysupport. Based on your answers, you may get a call from a nurse. Our specially-trained team will work with you to answer any questions and give advice between doctor visits. You will also gain access to digital pregnancy content in your HealthPartners account and through email. It’s all written by our health experts and timed to where you’re at in your pregnancy.

High option members enrolled in both Medicare Part A and Part B are eligible to be reimbursed up to $1,200 per calendar year for their Medicare Part B premium payments. Eligible members must have an healthpartners.com/pshb account and notify HealthPartners of their Medicare enrollment status. To receive Part B premium reimbursement, eligible members must submit proof of Part B premium payment no later than March 31 of the following year. For more information on how to get reimbursement for your paid Medicare Part B premiums, please call 844-440-1900 or visit healthpartners.com/pshb/medicare.

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).

You may be eligible for an eyewear discount at Plan optical centers, including HealthPartners Eye Care Centers and EyeMed retailers such as Target, LensCrafters, etc. For more information on the program visit www.healthpartners.com/pshb or call member services at 844-440-1900.

HealthPartners retail savings program gives you discounts on tools and services from reputable organizations to help you be as healthy as you can be. Complete information and list of partner organizations can be found online at www.healthpartners.com/pshb or call member services at 844-440-1900.

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 844-440-1900 (TTY: 711), or at our website at 
www.healthpartners.com/pshb.

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

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

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

Submit your claims to:

HealthPartners Claims
PO Box 21024
Eagan, MN 55121

Submit your PSHB claims to:

HealthPartners Claims
PO Box 21024
Eagan, MN 55121

Submit your PDP EGWP claims to:

HealthPartners Pharmacy Department
P.O. Box 1309
MS 21111B
Minneapolis, MN 55440-1309

Submit your claims to:

HealthPartners Claims
PO Box 21024
Eagan, MN 55121

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, we will permit a healthcare professional with knowledge of your medical condition to act as your authorized representative without your express consent. For the purposes of this section, we are also referring to your authorized representative when we refer to you.

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

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

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

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

b) Send your request to us at: Riverview Member Rights and Benefits, PO Box 21662, Eagan, MN 55121; 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, NW; Room 3443
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;
• 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 prior approval. This is the only deadline that may not be extended.

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

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

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

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

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. For example, we will generally only make up the difference between the primary payor’s benefits payment and 100% of the Plan allowance, subject to our applicable coinsurance or copayment amounts, except when Medicare is the primary payor (see page (Applies to printed brochure only)). Thus, it is possible that the combined payments from both plans may not equal the entire amount billed by the provider.

Note: When we pay secondary to primary coverage you have from a prepaid plan (HMO), we base our benefits on your out-of-pocket liability under the prepaid plan (generally, the prepaid plan’s copayments), subject to our coinsurance or copayment amounts. In certain circumstances when we are secondary and there is no adverse effect on you (that is, you do not pay any more), we may also take advantage of any provider discount arrangements your primary plan may have and only make up the difference between the primary plan’s payment and the amount the provider has agreed to accept as payment in full from the primary plan.

Note: Any visit limitations that apply to your care under this Plan are still in effect when we are the secondary payor. Remember: Even if you do not file a claim with your other plan, you must still tell us that you have double coverage, and you must also send us documents about your other coverage if we ask for them.

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.

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

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

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

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

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

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

Some 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.gov 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 the PSHB Helpline at 844-451-1261.

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 844-440-1900.

To be eligible for full cost-share waiving, members must be enrolled in both Parts A and B of Original Medicare. For members enrolled in High and Standard Option and also enrolled in the Original Medicare Plan (Part A and B) as your primary payor – we will waive your out-of-pocket costs (applicable deductibles, copays and coinsurance) at in-network providers as follows:

• Inpatient hospital benefits: We waive applicable deductibles, copays and coinsurance.
• Medical and surgery benefits and mental health/substance use disorder care: We waive applicable deductibles, copays and coinsurance.
• Office visits: We waive the applicable deductibles, copays and coinsurance at In-Network Providers.
• Physical, speech and occupational therapy benefits: Applicable deductibles, copays and coinsurance is waived.
• Benefit limits and maximums still apply.
• There is no change to your prescription drug coverage. We do not waive deductibles, copays, or coinsurance.
• We do not waive cost-sharing on hearing aids through TruHearing.

You can find more information about how our Plan coordinates benefits with Medicare by calling our PSHB Member Services team at 844-440-1900 or visit healthpartners.com/pshb/medicare.

Cost sharing may not apply if the Original Medicare Plan is your primary payor

– For Medicare covered services we will coordinate benefits to potentially reduce your out-of-pocket costs as follows:

When Medicare Part A is primary –

• You may experience a reduction in cost sharing for our in-network:
  • Annual hospital copayments for Medicare covered services;
  • Hospital coinsurance for Medicare covered services.

Note: Once you have exhausted your Medicare Part A benefits, you must then pay the applicable copayment or coinsurance.

When Medicare Part B is primary –

• You may experience a reduction in cost sharing for our in-network:
  • Coinsurance and copayments for inpatient and outpatient services and supplies provided by physicians and other covered healthcare professionals for Medicare covered services; and
  • Coinsurance and/or copayment for outpatient facility services for Medicare covered services.

Note: We do not waive benefit limitations, such as the 25-visit limit for home nursing visits. In addition, we do not waive any coinsurance or copayments for prescription drugs.

A physician may ask you to sign a private contract agreeing that you can be billed directly for services ordinarily covered by Original Medicare. Should you sign an agreement, Medicare will not pay any portion of the charges, and we will not increase our payment. We will still limit our payment to the amount we would have paid after Original Medicare’s payment. You may be responsible for paying the difference between the billed amount and the amount we paid.

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

Benefit Description: Deductible
High Option You Pay Without Medicare: $0
High Option You Pay With Medicare Part B: $0
Standard Option You Pay Without Medicare: In-Network: $750/Self Only; $1,500/Self Plus One; $1,500/Family; Out-of-Network: $2,000/Self Only; $4,000/Self Plus One; $4,000/Family
Standard Option You Pay With Medicare: In-Network: $0; Out-of-Network: $2,000/Self Only; $4,000/Self Plus One; $4,000/Family

Benefit Description: Out-of-Pocket Maximum
High Option You Pay Without Medicare: Self Only: Nothing after $6,500; Self Plus One: Nothing after $13,000, subject to a maximum of $9,200 per enrollee; Self and Family: Nothing after $13,000, subject to a maximum of $9,200 per enrollee
High Option You Pay With Medicare Part B: Self Only: Nothing after $6,500; Self Plus One: Nothing after $13,000, subject to a maximum of $9,200 per enrollee; Self and Family: Nothing after $13,000, subject to a maximum of $9,200 per enrollee
Standard Option You Pay Without Medicare: In-Network: Self Only: Nothing after $7,500; Self Plus One: Nothing after $15,000, subject to a maximum of $9,200 per enrollee; Self and Family: Nothing after $15,000, subject to a maximum of $9,200 per enrollee; Out-of-Network: No maximum
Standard Option You Pay With Medicare: In-Network: Self Only: Nothing after $7,500; Self Plus One: Nothing after $15,000, subject to a maximum of $9,200 per enrollee; Self and Family: Nothing after $15,000, subject to a maximum of $9,200 per enrollee; Out-of-Network: No maximum

Benefit Description: Part B Premium Reimbursement Offered
High Option You Pay Without Medicare: NA
High Option You Pay With Medicare Part B: Up to $1,200
Standard Option You Pay Without Medicare: NA
Standard Option You Pay With Medicare: None

Benefit Description: Primary Care Provider
High Option You Pay Without Medicare: $45
High Option You Pay With Medicare Part B: Nothing for most Medicare covered services and never more than $45
Standard Option You Pay Without Medicare: In-Network: You pay $0 for 5 visits, then 20% after deductible; Out-of-Network: 40% after deductible
Standard Option You Pay With Medicare: In-Network: Nothing for most Medicare covered services and never more than 20% after deductible; Out-of-Network: Nothing for most Medicare covered services and never more than 40% after deductible

Benefit Description: Specialist
High Option You Pay Without Medicare: $45
High Option You Pay With Medicare Part B: Nothing for most Medicare covered services and never more than $45
Standard Option You Pay Without Medicare: In-Network: 20% after deductible; Out-of-Network: 40% after deductible
Standard Option You Pay With Medicare: In-Network: Nothing for most Medicare covered services and never more than 20% after deductible; Out-of-Network: Nothing for most Medicare covered services and never more than 40% after deductible

Benefit Description: Inpatient Hospital
High Option You Pay Without Medicare: $500 hospital deductible for inpatient & outpatient combined, then 20% of charges
High Option You Pay With Medicare Part B: Nothing for most Medicare covered services and never more than a $500 hospital deductible for inpatient & outpatient combined, then 20% of charges
Standard Option You Pay Without Medicare: In-Network: 20% after deductible; Out-of-Network: 40% after deductible
Standard Option You Pay With Medicare: In-Network: Nothing for most Medicare covered services and never more than 20% after deductible; Out-of-Network: Nothing for most Medicare covered services and never more than 40% after deductible

Benefit Description: Outpatient Surgery - Hospital
High Option You Pay Without Medicare: $500 hospital deductible for inpatient & outpatient combined, then 20% of charges
High Option You Pay With Medicare Part B: Nothing for most Medicare covered services and never more than a $500 hospital deductible for inpatient & outpatient combined, then 20% of charges
Standard Option You Pay Without Medicare: In-Network: 20% after deductible; Out-of-Network: 40% after deductible
Standard Option You Pay With Medicare: In-Network: Nothing for most Medicare covered services and never more than 20% after deductible; Out-of-Network: Nothing for most Medicare covered services and never more than 40% after deductible

Benefit Description: Incentives Offered
High Option You Pay Without Medicare: N/A
High Option You Pay With Medicare Part B: Health assessment and wellness courses. For more information see page (Applies to printed brochure only)
Standard Option You Pay Without Medicare: N/A
Standard Option You Pay With Medicare: Health assessment and wellness courses. For more information see page (Applies to printed brochure only)

You can find more information about how our plan coordinates benefits with Medicare by visiting
www.healthpartners.com/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 health plan does not coordinate its prescription drug benefits with Medicare Part B.

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

To learn more about Medicare Advantage plans, contact Medicare at 800-MEDICARE (800-633-4227) (TTY: 877-486-2048) or at www.medicare.gov or call us at 844-440-1900 (TTY: 711) or see our website at www.healthpartners.com/pshb.

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

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

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

Suspended PSHB coverage to enroll in a Medicare Advantage plan: If you are an annuitant, you can suspend your PSHB coverage to enroll in a 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.

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.

If you are enrolled in the HealthPartners PDP, when your Part D prescription drug copayments and/or coinsurance total $2,000 in a calendar year, you do not have to pay any more for covered Part D prescription drugs for the remainder of that calendar year.

If you are enrolled in Medicare Part A and/or Part B, 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 HealthPartners Member Services at 844-440-1900.

The PDP EGWP opt out process:
If you were automatically group enrolled into our PDP EGWP and choose to opt out, contact us at 844-440-1900.

The PDP EGWP disenrollment process:
When you are enrolled in our PDP EGWP, you may choose to disenroll at any time. To opt-out of enrollment in the PDP, call Member Services at 844-440-1900.

Warning: If you opt out of or disenroll from our PDP EGWP, you will not have any PSHB Program prescription drug coverage.

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 844-440-1900.

Members enrolled in the HealthPartners PDP combined with our High Option plan will have reduced cost-sharing for some Part D drugs.
Tier 1 – Preferred Generic Drugs: $5 copay
Tier 2 – Generic Drugs: $20 copay
Tier 3 – Preferred Brand Drugs: $47 copay
Tier 4 – Non-preferred Drugs: 40% coinsurance
Tier 5 – Specialty Drugs: 33% coinsurance
Part D Annual Out-of-Pocket Maximum: $2,000

Members enrolled in the HealthPartners PDP combined with our Standard Option plan will have reduced cost-sharing for some Part D drugs.
Deductible: $590
Tier 1 – Preferred Generic Drugs: $5 copay
Tier 2 – Generic Drugs: $20 copay
Tier 3 – Preferred Brand Drugs: $47 copay after deductible
Tier 4 – Non-preferred Drugs: 40% coinsurance after deductible
Tier 5 – Specialty Drugs: 25% coinsurance after deductible
Part D Annual Out-of-Pocket Maximum: $2,000

• 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.

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

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

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

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

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

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

This is equipment which can withstand repeated use, is primarily and customarily used to serve a medical purpose, generally is not useful to a person in the absence of an illness or injury, and is appropriate for use in the home.

As determined by us, a drug, device, medical, behavioral health or dental treatment is investigative if reliable evidence does not permit conclusions concerning its safety, effectiveness, or positive effect on health outcomes and will be considered investigative unless all of the following categories of reliable evidence are met:

• There is final approval from the appropriate government regulatory agency, if required. This includes whether a drug or device can be lawfully marketed for its proposed use by the United States Food and Drug Administration (FDA); and
• The drug or device or medical, behavioral health or dental treatment or procedure is not the subject of ongoing Phase I, II or III clinical trials; and
• The drug, device or medical, behavioral health or dental treatment or procedure is not under study and further studies are not needed (such as post-marketing clinical trial requirements) to determine maximum tolerated dose, toxicity, safety, effect on health outcomes or efficacy as compared to existing standard means of treatment or diagnosis; and
• There is conclusive evidence in major peer-reviewed medical journals demonstrating the safety, effectiveness and positive effect on health outcomes (the beneficial effects outweigh any harmful effects) of the service or treatment when compared to standard established service or treatment. Each article must be of well-designed investigations, using generally acceptable scientific standards that have been produced by nonaffiliated, authoritative sources with measurable results. Case reports do not satisfy this criterion. This also includes consideration of whether a drug is included in one of the standard reference compendia or “Major Peer Reviewed Medical Literature” (defined below) for use in the determination of a medically necessary accepted indication of drugs and biologicals used off-label as appropriate for its proposed use.

Major Peer Reviewed Medical Literature. This means articles from major peer reviewed medical journals that have recognized the drug or combination of drugs' safety and effectiveness for treatment of the indication for which it has been prescribed. Each article shall meet the uniform requirements for manuscripts submitted to biomedical journals established by the International Committee of Medical Journal Editors or be published in a journal specified by the United States Secretary of Health and Human Services pursuant to United States Code, title 42, section 1395x, paragraph (t), clause (2), item (B), as amended, as acceptable peer review medical literature. Each article must use generally acceptable scientific standards and must not use case reports to satisfy this criterion.

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

Infertility is the failure to achieve a successful pregnancy after regular, unprotected intercourse or artificial insemination for 12 months or more (6 months for individuals with female reproductive organs over age 35). Evaluation may be justified based on medical history and diagnostic testing. Infertility may also be established through an evaluation based on medical history and diagnostic testing.

This plan defines medically necessary care as care that is appropriate for the condition, including those related to mental health. It includes the kind and level of service. It includes the number of treatments. It also includes where you get the service and how long it continues. Medically necessary care must:

• Be the service that other providers would usually order
• Help you get better, or stay as well as you are
• Help stop the condition from getting worse
• Help prevent and find health problems

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.

These are items, medical equipment or medicines available without a prescription.

Plan allowance is the amount we use to determine our payment and your coinsurance for covered services. Plans determine their allowances in different ways.

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

We determine our allowance as follows:

• For covered services delivered by Plan providers, Plan referral providers, or out-of-network providers that have a contract with us, our allowance is the provider’s contracted rate for a given medical/surgical service, procedure or item, which Plan providers have agreed to accept as payment in full.
• For covered services delivered by non-Plan providers that do not have a contract with us, our allowance is the provider’s charge for a given medical/surgical service, procedure or item, according to the usual and customary charge amount.
• The usual and customary charge is the maximum amount allowed that we consider in the calculation of the payment of charges incurred for certain covered services. You must pay for any charges above the usual and customary charge, and they do not apply to the deductible or catastrophic protection out-of-pocket maximum

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 prior approval, or a referral and (2) where failure to obtain 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 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 worker's 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.

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

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

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

Urgent care claims usually involve pre-service claims and 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. You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

Us and we have the same meaning as HealthPartners and its related organizations.

The usual and customary charge is the maximum amount allowed that we consider in the calculation of the payment of charges incurred for certain covered services received from Out-of-Network providers. It is consistent with the range of reasonable fees charged by other providers of a given service or item in the same geographic region.

The usual and customary charge is determined using one of the following options in the following order, depending on availability: 1) a percentage of the Medicare fee schedule; 2) a comparable schedule if the service is not on the Medicare fee schedule; or 3) a commercially reasonable rate for such service.

You must pay for any charges above the usual and customary charge, and they do not apply to the deductible or catastrophic protection out-of-pocket maximum.

You refers to the enrollee and each covered family member.

$10 per convenience clinic visit; $45 per office visit; $45 per urgent care visit; nothing for Virtuwell evisits

(Applies to printed brochure only)

Nothing

(Applies to printed brochure only)

$500 hospital deductible for inpatient & outpatient combined, then 20% of charges

(Applies to printed brochure only)

$250 per emergency room visit; $45 per office or urgent care center visit

(Applies to printed brochure only)

Regular cost-sharing

(Applies to printed brochure only)

$5 for low cost generic formulary drugs; $25 for high cost generic formulary drugs; $75 for preferred brand-name formulary drugs; 40% coinsurance for non-preferred brand-name formulary drugs

(Applies to printed brochure only)

$10 for low cost generic formulary drugs; $50 for high cost generic formulary drugs; $150 for preferred brand-name formulary drugs; 40% coinsurance for non-preferred brand-name formulary drugs

(Applies to printed brochure only)

40% coinsurance for specialty drugs

(Applies to printed brochure only)

Tier 1 – Preferred Generic Drugs: $5 copay; Tier 2 – Generic Drugs: $20 copay; Tier 3 – Preferred Brand Drugs: $47 copay; Tier 4 – Non-preferred Drugs: 40% coinsurance; Tier 5 – Specialty Drugs: 33% coinsurance; Part D Annual Out-of-Pocket Maximum: $2,000

(Applies to printed brochure only)

20% of charges, if Network dentist provides care; 30% of charges when provided by Out-of-Network dentist if the injuries require immediate treatment.

(Applies to printed brochure only)

Nothing for preventive care

(Applies to printed brochure only)

Self Only: Nothing after $6,500; Self Plus One: Nothing after $13,000, subject to a maximum of $9,200 per enrollee; Self and Family: Nothing after $13,000, subject to a maximum of $9,200 per enrollee

(Applies to printed brochure only)

CareLine^® service, Nurse Navigator, Behavioral Health Personalized Assistance Line, special phone lines for deaf and hearing impaired, personalized member page on website, health improvement programs

(Applies to printed brochure only)

In-Network: $0 for 5 visits, then 20% after in-network deductible
Out-of-Network: 40% after out-of-network deductible

(Applies to printed brochure only)

Nothing

(Applies to printed brochure only)

In-Network: 20% after in-network deductible
Out-of-Network: 40% after out-of-network deductible

(Applies to printed brochure only)

20% after in-network deductible

(Applies to printed brochure only)

Regular cost-sharing

(Applies to printed brochure only)

In-Network: $5 for low cost generic formulary drugs; $25 for high cost generic formulary drugs; $75 for preferred brand name formulary drugs after in-network deductible; 40% coinsurance for non-preferred brand-name formulary drugs after in-network deductible.
Out-of-Network: 40% after out-of-network deductible.

(Applies to printed brochure only)

In-Network: $10 for low cost generic formulary drugs; $50 for high cost generic formulary drugs; $150 for preferred brand name formulary drugs after in-network deductible; 40% coinsurance for non-preferred brand-name formulary drugs after in-network deductible. Out-of-Network: all charges.

(Applies to printed brochure only)

In-Network: 40% coinsurance for specialty drugs, after in-network deductible
Out-of-Network: All charges

(Applies to printed brochure only)

Deductible: $590; Tier 1 – Preferred Generic Drugs: $5 copay; Tier 2 – Generic Drugs: $20 copay; Tier 3 – Preferred Brand Drugs: $47 copay after deductible; Tier 4 – Non-preferred Drugs: 40% coinsurance after deductible; Tier 5 – Specialty Drugs: 25% coinsurance after deductible; Part D Annual Out-of-Pocket Maximum: $2,000

(Applies to printed brochure only)

In-Network: 20% after in-network deductible. Out-of-Network: 30% after in-network deductible.

(Applies to printed brochure only)

Nothing for preventive care

(Applies to printed brochure only)

In-Network: Self Only: Nothing after $7,500; Self Plus One: Nothing after $15,000, subject to a maximum of $9,200 per enrollee; Self and Family: Nothing after $15,000, subject to a maximum of $9,200 per enrollee; Out-of-Network: no maximum

(Applies to printed brochure only)

CareLine^® service, Nurse Navigator, Behavioral Health Personalized Assistance Line, special phone lines for deaf and hearing impaired, personalized member page on website, health improvement programs

(Applies to printed brochure only)