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 PSHBP Helpline at (844) 451-1261. When you change to Self Plus One or Self and Family because you marry, the change is effective on the first day of the pay period that begins after your employing office receives your enrollment request. Benefits will not be available to your spouse until you are married. A carrier may request that an enrollee verify the eligibility of any or all family members listed as covered under the enrollee’s PSHB enrollment.

Use the PSHB System if you want to change from Self Only to Self Plus One or Self and Family, and to add or remove a family member. 

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits. Please report changes in family member status, including your marriage, divorce, annulment, or when your child reaches age 26 through the PSHB System. We will send written notice to you 60 days before we proactively disenroll your child on midnight of their 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 in the chart below. A Self Plus One enrollment covers you and your spouse, or one other eligible family member, as described below.

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

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

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

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

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

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

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

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

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

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

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

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

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

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 or contact us at 800-315-3144 (TYY: 711) or at our website at www.MedMutual.com/PSHB.

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 800-315-3144 (TTY: 711).

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

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

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

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

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

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

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

Your benefits and rates will differ from those under the PSHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed, and your coverage will not be limited due to pre-existing conditions. When you contact us we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act’s Health Insurance Marketplace in your state. For assistance in finding coverage, please contact us at 800-315-3144 (TTY: 711) or visit our website at www.MedMutual.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 will 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 800-315-3144 (TTY: 711) or write to us at Medical Mutual of Ohio, Customer Care, PO Box 6018, Cleveland, OH 44101-1018. You may also request replacement cards through our website:
www.MedMutual.com/PSHB.

You get care from “Plan providers” and “Plan facilities.” You will only pay cost-sharing as defined in Section 10, Definitions of terms we use in this brochure.  

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 provider directory, which we update periodically. The list is also on our website.

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

This plan provides Care Coordinators for complex conditions and can be reached at 800-315-3144 (TTY: 711) for assistance.

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

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

Your primary care provider can be a Physician or group of Physicians, advanced nurse practitioners trained in family or general practice, geriatrics, internal medicine, obstetrics/gynecology or neonatology/pediatric medicine. Your primary care provider will provide most of your healthcare or give you a referral to see a specialist.

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

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

Specialty care is care you receive from providers other than a primary care provider. You may pay different cost-sharing for your specialty care. A referral is not required to see a specialist that is participating in your network. You may make appointments directly with these providers.

You generally must receive your care from a participating Network provider. However, if your Network provider determines that covered services are not available from participating In Network providers, they will need to obtain authorization in advance for a referral, you may seek the initial consultation from the specialist to whom you are referred. You must then return to your Network provider after the consultation, unless your referral authorizes a certain number of additional visits without the need to obtain another referral. In order to receive covered follow up care from an Out of Network specialist, the provider must first obtain authorization from us. Do not go to an Out of Network provider for return visits until you have received written authorization from us for additional services. Services, drugs and supplies related to a covered abortion (see Section 6. General exclusions- services, drugs and supplies we do not cover), are covered. Please contact Medical Mutual for information on how to access this coverage including claims related issues at 800-315-3144.

• If you are seeing a specialist when you enroll in our Plan, talk to your primary care provider. Your primary care provider will decide what treatment you need. If they decide to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.
• If you are seeing a specialist and your specialist leaves the Plan, call your primary care provider, who will work with you to identify another specialist for you to see.
• If you have a chronic and disabling condition and
  • lose access to your specialist because your coverage changed from the FEHB to the PSHB and your health plan does not participate in the PSHB; or
  • lose access to your specialist because we drop out of the Postal Service Employees Health Benefits (PSHB) Program and you enroll in another PSHB program plan; or:
  • lose access to your specialist because we terminate our contract with your specialist for other than cause; or
  • lose access to your specialist because we reduce our service area and you enroll in another PSHB plan;

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

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

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

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 800-315-3144 (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.

For certain services, your Plan provider must obtain approval from us.  Before giving approval, we may consider if the service or item is medically necessary and meets other coverage requirements.  We call this review and approval process precertification.

Your Plan provider must obtain precertification for:

• Inpatient hospital care services, surgery and procedures
• Certain Outpatient surgeries, call customer service for information
• Non-emergency Ambulance transport, including air ambulance
• Bariatric surgery and related services
• Chemotherapy
• Clinical trials
• Cosmetic, reconstructive and plastic surgery
• Durable medical equipment (DME) and orthopedic and prosthetic devices
• Inpatient services for behavioral health and alcohol and chemical dependency
• Injections/infusions
• Organ/tissue transplants and related services
• Skilled Nursing Facility
• Hyperbaric oxygen
• Dental Related Procedures due to accident or injury
• Genetic Testing (including but not limited to BRCA1 and BRCA2)
• Services or items from a non-Plan Provider or at non-Plan facilities
• Gender Reassignment surgery and related services

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

Your primary care 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. You must obtain prior authorization for:

• Transplants

First, your physician, your hospital, you, or your representative, must call us at 800-315-3144 (TTY: 711) before admission or services requiring prior authorization are rendered.

Next, provide the following information:

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

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

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

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

If you fail to provide sufficient information, we will contact you 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 800-315-3144 (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 800-315-3144 (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 cause emergency admission due to a condition that you reasonably believe puts your life in danger or could serious damage to bodily function, you, your representative, the physician, or the hospital must telephone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital.

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

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

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

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

If you have a pre-service claim and you do not agree with our decision regarding precertification of an inpatient admission or prior approval of other services, you may request a review in accord with the procedures detailed below. If your claim is in reference to a contraceptive, call 800-315-3144 (TTY: 711).

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.
3. 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.

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 telephone, electronic mail, facsimile, or other expeditious methods.

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

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

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

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

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

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

• The Standard Option has no calendar year deductible. 
• The calendar year deductible is $750 per person under the Basic Option. 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 the Basic Option. Under a Self Plus One enrollment, the deductible is considered satisfied and benefits are payable for you and one other eligible family member when the combined covered expenses applied to the calendar year deductible for your enrollment reach $1,500 under the Basic Option. 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 under the Basic Option.

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 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 50% of our allowance for infertility services and durable medical equipment

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

After your (copayments and coinsurance) total $6,000 for Self Only or $12,000 per person for Self Plus One, or $12,000 per Self and Family enrollment (for the Standard Option) or $6,500 for Self Only or $13,000 per person for Self Plus One, or $13,000 per Self and Family enrollment (for the Basic option) in any calendar year, you do not have to pay any more for covered services. 

However, copayments for the following services do not count toward your catastrophic protection out-of-pocke maximum, and you must continue to pay copayments for these services.

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

If you are enrolled in our Medicare Prescription Drug Plan (PDP) Employer Group Waiver Plan (EGWP), the prescription drug out-of-pocket maximum is $1,000.  After this maximum is met, we pay 100% of all eligible covered prescription drug benefits.

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

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

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

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

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

In-network services are services provided by a MedFlex provider.

A surprise bill is an unexpected bill you receive for:

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

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

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

In addition, your health plan adopts and complies with the surprise billing laws of Ohio.

For specific information on surprise billing, the rights and protections you have, and your responsibilities go to

https://www.medmutual.com/Employers/No-Surprises-Act-Transparency-Under-the-Consolidated-Appropriations-Act-2021.aspx

or contact the health plan at 800-315-3144 (TTY: 711).

Professional services of physicians and other health care professionals

• In a physician's office
• Office medical consultations
• Second surgical opinions
• Advance care planning

$25 per primary care office visit

$45 per specialty care office visit

$30 per primary care office visit

$60 per specialty care

Professional services of physicians

• In an urgent care center

$35 per visit

$45 per visit

Professional services of physicians and other health care professionals

• In ambulatory surgical centers
• At home by a physician
• During a hospital stay
• In a skilled nursing facility

Nothing

20% of the Plan allowance (deductible applies)

Services not performed in-person

When performed by a Provider with whom Medical Mutual has an agreement to perform these services, your coverage will include:

• Providers' charges for consulting by telephone, facsimile machine, electronic mail systems or online services.
• Online covered services include a medical consultation using the internet via a webcam, chat or voice.

$25 per primary care office visit

$45 per specialty care office visit

$30 per primary care office visit

$60 per specialty care

Not covered

Non covered services include, but are not limited to, communications used for:

• Reporting normal lab or other test results
• Office appointment requests
• Billing, insurance coverage or payment questions
• Requests for referrals to doctors outside the online care panel
• Benefit precertification
• Physician-to-Physician consultation

All charges

All charges

Tests, such as:

• Blood tests
• Urinalysis
• Non-routine pap test
• Pathology
• X-ray
• Non-routine mammogram
• CT Scans/MRI
• Ultrasound
• Electrocardiogram and EEG
• Nuclear medicine
• PET scans

Note: Tests related to infertility are covered under the infertility services benefit. See Section 5(a), Infertility services.

Nothing

20% of the Plan allowance (deductible applies)

Routine physical every year:

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

• U.S. Preventive Services Task Force (USPSTF) A and B recommended screenings such as cancer, osteoporosis, depression, diabetes, high blood pressure, total blood cholesterol, HIV, and colorectal cancer. 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, 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://www.health.gov/myhealthfinder
• Routine mammogram - including 3D mammograms
• Adult Immunizations-endorsed by the Centers for Disease Control and Prevention (CDC): based on the Advisory Committee on Immunization Practices (ACIP) schedule. For a complete list of endorsed immunizations go to the Centers for Disease Control (CDC) website at https://www.cdc.gov/vaccines/schedules/

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

• Routine exams limited to
  • One routine eye exam every 12 months

Nothing

Nothing

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

• Intensive nutrition and behavioral weight-loss counseling therapy
• Behavioral Counseling to Promote a Healthy Diet - Intensive behavioral dietary counseling for adults with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic diseases.
• Family centered programs when medically identified to support obesity

Note: Also see Section 5(h)

• 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

Nothing

Not covered:

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

All charges

All charges

• 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://www.brightfutures.aap.org
• Children’s immunization’s endorsed by the Centers for Disease Control (CDC) including DTaP/Tdap, Polio, Measles, Mumps, and Rubella (MMR), and Varicella. For a complete list of immunizations go to the website at https://www.cdc.gov/vaccines/schedules/index.html
• 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
• To build your personalized list of preventive services go to https://www.health.gov/myhealthfinder

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

Nothing

Nothing

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

• Intensive nutrition and behavioral weight-loss counseling therapy,
• Behavioral Counseling to Promote a Healthy Diet - Intensive behavioral dietary counseling for adults with hyperlipidemia and other known risk factors for cardiovascular and diet-related chronic diseases.
• Family centered programs when medically identified to support obesity prevention and management by an in-network provider.

Nothing

Nothing

• 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.

Nothing

Nothing

• When Bariatric or Metabolic surgical treatment or intervention is for severe obesity.  See Section 5(b) for surgery requirements and cost share.

Nothing

Nothing

Complete maternity (obstetrical) care, such as:

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

Nothing

Nothing

Breastfeeding and lactation support, supplies and counseling for each birth

Note: Here are some things to keep in mind:

You do not need to precertify your vaginal delivery; see page 21 for other circumstances, such as extended stays for you or your baby.

Nothing

Nothing

• 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 during the covered portion of the mother’s maternity stay. We will cover other care of an infant who requires non-routine treatment only if we cover the infant under a Self Plus One or Self and Family enrollment. 
• We pay hospitalization and surgeon services for non-maternity care the same as for illness and injury.
• Hospital services are covered under Section 5(c) and Surgical benefits Section 5(b).

   

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

Nothing

Nothing

Contraceptive counseling on an annual basis

Nothing

Nothing

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

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

If the attending Physician determines a particular service or FDA-approved item is required for medical reasons, Medical Mutual will cover that Contraceptive service or item without cost sharing.

Surgical Contraceptive Assistance

If you need information regarding which contraceptives are covered on your plan including surgical contraceptive services,  contact our Customer Care at 1-800-315-3144.  You plan covers tubal ligations without a cost share.  Pre-authorization is only required for surgeries that required an inpatient admission.  We will respond to any inquires you have regarding contraceptive services within 24 hours.

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

Nothing

Nothing

Voluntary male sterilization 

$25 per office visit

$30 per office visit

Not covered:

• Reversal of voluntary surgical sterilization
• Genetic testing and counseling

All charges

All Charges

Infertility is defined as not being able to conceive after 1 year of unprotected sex when the individual with female reproductive organs is under 35 years of age, 6 months of unprotected sex for an individual with female reproductive organs aged 35 years and older, or 12 months of attempts of artificial insemination (6 months for individuals 35 years of age and older). Infertility may also be defined by demonstration of a disease or condition of the reproductive tract such that unprotected sex or artificial insemination would be ineffective. There are many approaches to management of infertility, including traditional fertility treatments such as artificial insemination. Options for use of artificial insemination include intrauterine insemination (IUI), intracervical insemination (ICI), and intravaginal insemination (IVI). Treatment may be permitted based on medical history or diagnostic testing.

Diagnosis and treatment of infertility specific to:

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

The plan will cover three cycles (annually) of artificial insemination procedures/services.

The following infertility services are considered medically necessary and eligible for reimbursement when provided by in-network providers:

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

• Therapeutic injection of drugs or hormones
• Sperm preparation/washing for artificial insemination

30% of the Plan Allowance

Nothing for inpatient

50% of the Plan Allowance (deductible applies)

• Fertility drugs (See Section 5(f) or 5(f)(a), if applicable

30% of the Plan Allowance

Nothing for inpatient

50% of the Plan Allowance (deductible applies)

Not covered: 

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

• Assisted reproductive technology (ART) procedures, including related services and supplies, such as:
  • in vitro fertilization (IVF)
  • embryo transfer and gamete infra-fallopian transfer (GIFT) and zygote infra-fallopian transfer (Z1FT)

• Sperm and eggs (whether from a member or from a donor) and services and supplies related to their procurement and storage, including freezing
• Ovum transplants for fertile members
• Infertility services when either member of the family has been voluntarily surgically sterilized
• Services to reverse voluntary, surgically induced infertility
• Services for surrogate mothers who are not Plan members
• Preimplantation Genetic Diagnosis (PGD)
• Services that are not FDA supported or supported by evidence based guidelines

Services provided by out-of-network providers

All charges

All charges

Iatrogenic Infertility services

Coverage is provided for standard fertility preservation procedures for men and women as recognized by the American Society for Reproductive Medicine (ASRM) and/or American Society of Clinical Oncology (ASCO) for anyone facing the possibility of "iatrogenic infertility," that is, infertility caused by a necessary medical intervention.

This type of coverage does not include:

• Elective fertility preservation, such as egg freezing sought due to natural aging
• Infertility treatments such as in vitro fertilization that might be needed after the necessary medical intervention, such as a cancer treatment to achieve a pregnancy; or
• Long-term storage costs

Note: All the infertility service exclusions listed in the Not Covered section above also apply to the Iatrogenic Infertility services.

30% of the Plan allowance

Nothing for inpatient

50% of the Plan allowance (deductible applies)

• Testing 

$25 per primary care office visit

$45 per specialty care office visit

20% of the Plan allowance (deductible applies)

• Treatment

Nothing

Nothing

• Allergy serum

Nothing

Nothing

Not covered:

• Sublingual allergy desensitization

All charges

All charges

• Cardiac rehabilitation

$25 per outpatient office visit

20% of the Plan allowance (deductible applies)

• Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on page 47.

$25 per office visit

20% of the Plan allowance (deductible applies)

• Dialysis – hemodialysis and peritoneal dialysis
• Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy
  
  Note: Intravenous (IV)/Infusion Therapy requires our prior approval. See Section 3, You need prior Plan approval for certain benefits.

$25 per office visit, except Nothing if received in the home

20% of the Plan allowance (deductible applies)

• Growth hormone therapy (GHT)

• Note: Growth hormone requires our prior approval and is covered under the prescription drug benefit. See Section 3, You need prior Plan approval for certain benefits and Section 5(1), Prescription drug benefits.

$25 per office visit

20% of the Plan allowance (deductible applies)

• Respiration and inhalation therapy

Nothing

20% of the Plan allowance (deductible applies)

• Medical Nutrition Therapy - Behavioral Counseling for pregnant women to promote a healthy diet
• Medical Nutrition Therapy - Behavioral Counseling for children with Phenylketonuria (PKU)
• *Must meet specific medical criteria

First nine visits - Nothing

After initial nine preventive visits - Nothing

First nine visits ­Nothing

After initial nine preventive visits- 20% of the Plan allowance (deductible applies)

Applied Behavioral Analysis Therapy (ABA) - Autism Spectrum Disorder

• All ages and services are covered subject to the corresponding medical benefit, except the following limits that apply to the Outpatient therapies per calendar year: Occupational Therapy - 60 visits per calendar year; Speech Therapy - 60 visits per calendar year; Physical Therapy ­unlimited

$25 per outpatient office visit

Nothing for inpatient

20% of the Plan allowance (deductible applies)

Not covered:

• Chemotherapy supported by a bone marrow transplant or with stem cell support for any diagnosis not listed as covered under Section 5(b), Organ/Tissue transplants.

All charges

All charges

60 visits per calendar year (combined benefit for Physical and Occupational Therapy):

• Physical habilitative and rehabilitative therapy by qualified physical therapists to attain or restore bodily function when you have a total or partial loss of bodily function due to illness or injury
• Occupational habilitative and rehabilitative therapy by occupational therapists to assist you in attaining or resuming self-care and improved functioning in other activities of daily life when you have a total or partial loss of bodily function due to illness or injury

$25 per outpatient office visit

Nothing per visit during covered inpatient admission

20% of the Plan allowance (deductible applies)

Not covered:

• Long-term therapy
• Exercise programs
• Maintenance therapy
• Cognitive rehabilitation programs
• Therapies done primarily for educational purposes
• Services provided by local, state and federal government agencies, including schools

All charges

All charges

Habilitative and rehabilitative services for 60 visits per calendar year.

$25 per outpatient office visit

Nothing per visit during covered inpatient admission.

20% of the Plan allowance (deductible applies)

Not covered:

• Therapies done primarily for educational purposes
• Therapy for tongue thrust in the absence of swallowing problems
• Voice therapy for occupation or performing arts
• Services provided by local, state, and federal government agencies including schools

All charges

All charges

• Hearing aids for children through age 17, if the hearing aids are prescribed, fitted, and dispensed by a licensed Plan audiologist

Notes:

• A single hearing aid providing hearing to both ears (binaural hearing aid) is considered two hearing aids for purposes of this benefit.
• For coverage of:

- Hearing screenings, see Section 5(a), Preventive care, children and, for any other hearing testing, see Section 5(a),     Diagnostic and treatment services.

- Audible prescription reading and speech generating devices, see Section 5(a), Durable medical equipment

All charges in excess of $1,000 for each hearing impaired ear every 36 months

All charges in excess if $1,000 for each hearing impaired ear every 36 months

Not covered:

• All other hearing testing, except as may be covered in Section 5(a), Diagnostic and treatment services and Section 5(a), Preventive care, children
• Hearing aids, including testing and examinations for them, for all persons age 18 and over.

All charges

All charges

• Diagnosis and treatment of diseases of the eye
• Eye refractions to determine the need for vision correction and provide a prescription for eyeglasses or contact lenses

$25 per primary care office visit

$45 per specialty care office visit

$30 per primary care office visit

$60 per specialty care office visit

Not covered:

• Eyeglass lenses or frames
• Contact lenses, examinations for contact lenses or the fitting of contact lenses
• Eye surgery solely for the purpose of correcting refractive defects of the eye
• Vision therapy, including orthoptics, visual training and eye exercises

All charges

All charges

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

$25 per primary care office visit

$45 per specialty care office visit

$30 per primary care office visit

$60 per specialty care office visit

Not covered:

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

All charges

All charges

• Artificial limbs and eyes
• Prosthetic sleeve or sock
• Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy
• Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.
• Internal prosthetic devices, such as artificial joints, pacemakers, and surgically implanted breast implant following mastectomy.

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.

20% of the Plan allowance

20% of the Plan allowance (deductible applies)

Not covered:

• Corrective shoes
• Foot orthotics and podiatric use devices, such as arch supports, heel pad and heel cups
• Corsets, trusses, elastic stockings, support hose, and other supportive devices
• Comfort, convenience, or luxury equipment or features
• Prosthetic devices, equipment, and supplies related to the treatment of sexual dysfunction
• Educational training in the use of the prosthetic devices and orthotic appliances
• Repairs, adjustments, or replacements due to misuse or loss

All charges

All charges

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

• Oxygen
• Hospital beds
• Wheelchairs
• Crutches
• Walkers
• Speech generating devices
• Blood glucose monitors
• Infant apnea monitors
• Commodes
• Apnea monitors
• Bilirubin lights (for home photo therapy for infants)
• Compression sleeves and gloves used in treatment of physical complications of mastectomy, including lymphedema

Notes:

• Durable medical equipment (DME) is equipment that is prescribed by a Plan physician; obtained through sources designated by the Plan; consistent with Medicare guidelines; intended for repeated use; primarily and customarily used to serve a medical or therapeutic purpose in the treatment of an illness or injury; designed for prolonged use and appropriate for use in the home.
• We cover only those standard items that are adequate to meet the medical needs of the member.

We may require you to return the equipment to us, or pay us the fair market price of the equipment, when it is no longer prescribed.

25% of the Plan allowance

30% of the Plan allowance (deductible applies)

Breastfeeding pump, including any equipment required for pump functionality

Note: We cover a 12 month rental.

Nothing

Nothing

Not covered:

• Audible prescription reading devices
• Comfort, convenience, or luxury equipment or features
• Non medical items such as sauna baths or elevators
• Exercise and hygiene equipment
• Electronic monitors of the heart, lungs, or other bodily functions, except for infant apnea monitors
• Devices to perform medical testing of bodily fluids, excretions, or substances, except blood glucose monitors for insulin dependent diabetics
• Devices, equipment, supplies, and prosthetics related to the treatment of sexual dysfunction disorders
• Modifications to the home or vehicle
• Repairs, adjustments, or replacements due to misuse or loss

All charges

All charges

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

Notes:

• We only provide these services in the Plan's service areas.
• The services are covered only if you are homebound and a Plan physician determines that it is feasible to maintain effective supervision and control of your care in your home.

Nothing

20% of the Plan allowance (deductible applies)

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.
• Custodial care
• Private duty nursing
• Personal care and hygiene items
• Care that a Plan provider determines may be appropriately provided in a Plan facility, hospital, skilled nursing facility or other facility we designate and we provide, or offer to provide, that care in one of these facilities

All charges

All charges

Up to 20 chiropractic visits per calendar year.

• Manipulation of the spine and extremities

Note: Participating chiropractors are listed at 
http://www.medmutual.com/PSHB

$25 per office visit

$30 per office visit

Not covered:

• Chiropractic appliances

All charges

All charges

No benefit

All charges

All charges

Coverage is provided for:

• Tobacco Cessation programs, including individual/group/telephone counseling, over-the-counter (OTC) and prescription drugs approved by the FDA to treat tobacco dependence.
• Diabetes self management

Nothing 

20% of the Plan allowance (deductible applies)

A comprehensive range of services, such as:

• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Correction of amblyopia and strabismus
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see Reconstructive surgery)
• Surgical treatment of severe obesity (bariatric surgery)

$25 per primary care office visit for outpatient services

$45 per specialty care office visit for outpatient services

Nothing for inpatient services

20% of the Plan allowance (deductible applies)

Bariatric Metabolic Surgery

Members must meet the following medical criteria to be eligible for coverage:
Age =18 years or adolescent aged 13 to 17 years; and
Severe, clinical obesity defined as at least one of the following:

1. BMI =40 kg/m² (=37.5 kg/m²⁾ for Asian patients when ethnicity is confirmed by provider attestation, or

2. BMI =35 kg/m² (=32.5 kg/m² for Asian patients when ethnicity is confirmed by provider attestation) with medical record documentation of high-risk comorbid clinical conditions including at least one of the following (presence and extent of comorbidities will be determined based upon review of medical record documentation):

and

1. Clinically significant cardiopulmonary problems (e.g., hypertension, sleep apnea, Pickwickian syndrome, obesity-related cardiomyopathy);
2. Diabetes mellitus; or
3. Physical problems severely interfering with function (e.g., joint disease that would be treatable except for the obesity or body size problems; employment or ambulation precluded by obesity); or
4. Evidence of fatty liver disease (e.g., nonalcoholic fatty liver disease [NAFLD], nonalcoholic steatohepatitis [NASH]);
   and
5. Unequivocal clearance for bariatric surgery by a licensed mental health provider that indicates the following: no behavioral health factors preclude a successful outcome of surgery, there is an absence of any major uncontrolled psychiatric disorders, and the individual is able to comply with the recommended medical/surgical preoperative and postoperative treatment plans (NOTE: The following will require clearance specifically by a licensed psychologist or psychiatrist: Members with a history of severe psychiatric disturbance; members currently under the care of a psychologist or psychiatrist; or members on psychotropic medications. Depression due to obesity is not normally considered a contraindication for obesity surgery); and
6. Medical clearance to proceed with surgery from appropriate specialties, such as cardiology, pulmonary medicine, or sleep medicine, related to existing comorbid disease states (providers that are board-certified in obesity medicine may meet these criteria); and
7. Information regarding probable and potential postoperative complications, dietary, and medical postoperative limitations, and potential cosmetic sequelae has been received by the individual; and
8. Medical record documentation or a documented clinical history by the provider of at least 12 months that supports all of the above criteria;

NOTE: If a patient, whose initial BMI is 40 kg/m² or greater, loses sufficient weight to fall just below the BMI cutoff due to participation in a preoperative weight-loss program, that patient may still be eligible for bariatric surgery based on their initial BMI determination.

Metabolic surgery may be considered as an option to treat type 2 diabetes in adults with BMI 30.0-34.9 kg/m² (27.5-32.4 kg/m² in Asian Americans) who do not achieve durable weight loss and improvement in comorbidities (including hyperglycemia) with nonsurgical methods.

Bariatric/Metabolic surgery will be provided according to guidelines set forth by the American Diabetes Association, the American Academy of Pediatrics (AAP), and the American Society for Metabolic and Bariatric Surgery.

See Section 3, You need prior Plan approval for certain services, for more information.

You will need to meet the above qualifications before your Plan provider will refer you to our bariatric surgery program. This program may refer you to other Plan providers to determine if you meet additional criteria necessary for bariatric surgery, including but not limited to nutritional, psychological, medical and social readiness for surgery. Final approval for surgical treatment will be required from the Medical Mutual of Ohio designated physician.

$25 per primary care office visit for outpatient services

$45 per specialty care office visit for outpatient services

Nothing for inpatient services

20% of the Plan allowance (deductible applies)

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

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

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)

$25 per primary care office visit for outpatient services

$45 per specialty care office visit for outpatient services

Nothing for inpatient services

20% of the Plan allowance (deductible applies)

Not covered:

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

All charges

All charges

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

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

• Gender Affirming Care and Services
  • Coverage for Gender Affirming Care and Services will be provided according to the World Professional Association for Transgender Health's (WPATH) Standards including facial feminization.
  • There are no exclusions for medically necessary gender affirming care surgeries.
  • Your Plan provider must obtain precertification from the plan prior to obtaining any gender reassignment surgery.
    
    Please see Section 3 for additional details regarding the "precertification" process.

$45 per office visit for outpatient services

Benefits paid based on services rendered

A $650 copayment applies for any inpatient hospitalizations

20% of the Plan allowance (deductible applies) for inpatient and outpatient services

Not covered:

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

All charges

All charges

Oral surgical procedures, limited to:

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

$45 per office visit for outpatient services

Nothing for inpatient services

20% of the Plan allowance (deductible applies)

Not covered:

• Oral implants and transplants
• Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone), except for procedures related to accidental injury of teeth
• Correction of any malocclusion not listed above
• Any dental care involved in treatment of temp oromandibularjoint (TMJ) pain dysfunction syndrome
• Dental services associated with medical treatment such as surgery and radiation treatment, except for services related to accidental injury of teeth (See Section 5(g))

All charges

All charges

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

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

$45 per office visit for outpatient services

Nothing for inpatient services

20% of the Plan allowance (deductible applies)

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

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

$45 per office visit for outpatient services

Nothing for inpatient services

20% of the Plan allowance (deductible applies)

Blood or marrow stem cell transplants

The Plan extends coverage for the diagnoses as indicated below.

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

$45 per office visit for outpatient services

Nothing for inpatient services

20% of the Plan allowance (deductible applies)

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

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

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

$45 per office visit for outpatient services

Nothing for inpatient services

20% of the Plan allowance (deductible applies)

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

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

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

$45 per office visit for outpatient services

Nothing for inpatient services

20% of the Plan allowance (deductible applies)

• National Transplant Program (NTP) –

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

$45 per office visit for outpatient services

Nothing for inpatient services

20% of the Plan allowance (deductible applies)

Not covered:

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

All charges

All charges

Professional services provided in –

• Hospital (inpatient)

Nothing

20% of the Plan allowance (deductible applies)

Professional services provided in –

• Hospital outpatient department
• Skilled nursing facility
• Ambulatory surgical center
• Office

Nothing

20% of the Plan allowance (deductible applies)

Room and board, such as:

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

Notes:

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

$650 per admission

20% of the Plan allowance (deductible applies)

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medications
• Diagnostic laboratory tests and x-rays
• Blood and blood products
• Dressings, splints, plaster casts, and sterile tray services
• Medical supplies, appliances, and equipment, including oxygen
• Anesthetics, including nurse anesthetist services
• The collection and storage of autologous blood for elective surgery when authorized by a Plan physician.

Note: You may receive covered hospital services for certain dental procedures if a Plan physician determines you need to be hospitalized for reasons unrelated to the dental procedure. The need for anesthesia, by itself, is not such a condition.

Nothing

20% of the Plan allowance (deductible applies)

Not covered:

• Custodial care and care in an intermediate care facility
• Non-covered facilities, such as nursing homes
• Personal comfort items, such as telephone, television, barber services, and guest meals and beds
• Private nursing care, except when medically necessary
• Inpatient dental procedures
• Cord blood procurement and storage for possible future need for a yet-to-be determined member recipient.

All charges

All charges

• Operating, recovery, and other treatment rooms
• Prescribed drugs and medications
• Lab, x-ray, and other diagnostic tests
• Blood and blood products
• The collection and storage of autologous blood for elective surgery, when authorized by a Plan physician
• Pre-surgical testing
• Dressing, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics and anesthesia service

$375 per outpatient surgery

20% of the plan allowance (deductible applies)

Not covered:

• Cord blood procurement and storage for possible future need or for a
  yet-to-be determined member recipient.

All charges

All charges

Up to 100 days per calendar year

• When you need full-time skilled nursing care

All necessary services are covered, including:

• Room and board
• General nursing care
• Medical social services
• Prescribed drugs, biologicals, supplies, and equipment, including oxygen, ordinarily provided or arranged by the skilled nursing facility

Nothing

20% of the Plan allowance (deductible applies)

Not covered:

• Custodial care and care in an intermediate care facility
• Personal comfort items, such as telephone, television, barber services, and guest meals and beds.

All charges

All charges

Supportive and palliative care for a terminally ill member:

• You must reside in the service area
• Services are provide
  • in the home, when a Plan physician determines that it is feasible to maintain effective supervision and control of your care in your home, or
  • in a Plan-approved hospice facility, if approved by a Plan physician

Services include inpatient care, outpatient care, and family counseling. A Plan physician must certify that you have a terminal illness, with a life expectancy of approximately six months or less.

Note:

Hospice is a program for caring for the terminally ill patient that emphasizes supportive services, such as home care and pain and symptom control, rather than curative care. A person who is terminally ill may elect to receive hospice benefits. These palliative and supportive services include nursing care, medical social services, therapy services for purposes of safety and symptom control, physician services, palliative drugs in accord with our drug formulary guidelines, medical supplies and equipment, and short-term inpatient care for pain control and acute and chronic symptom management. We also provide inpatient respite care, counseling, and bereavement services. If you make a hospice election, you are not entitled to receive other health care services that are related to the terminal illness. If you have made a hospice election, you may revoke that election at any time, and your standard health benefits will be covered.

Nothing

Nothing

Not covered:

• Independent nursing (private duty nursing)
• Homemaker services

All charges

All charges

• Local licensed ambulance service when medically necessary

Note: See Section 5 (d) for emergency services

$350 per trip

20% of the plan allowance (deductible applies)

Not covered:

• Transportation by car, taxi, bus, gurney van, wheelchair van, and any
  other type of transportation (other than a licensed ambulance), even if it is the only way to travel to a Plan Provider.

All charges

All charges

• Urgent care center

$35 per visit

$45 per visit

• Emergency care as an outpatient at an emergency facility, including physicians' services

Notes:

• We waive your emergency room copayment if you are directly admitted to a hospital as an inpatient. Your inpatient admission copayment will still apply (see Section 5(c)).

Transfers to an observation bed or observation status do not qualify as an admission to a hospital and your emergency copayment will not be waived.

$325 per visit

$325 per visit

Not covered:

• Elective care or non-emergency care
• Urgent care at a non-Plan urgent care center

All charges

All charges

• Urgent care center

$35 per visit

$45 per visit

• Emergency care as an outpatient in a hospital, including physicians' services

Notes:

• We waive your emergency room copayment if you are directly admitted to a hospital as an inpatient. Your inpatient admission copayment will still apply (See Section 5(c)).
• Transfers to an observation bed or observation status do not qualify as an admission to a hospital and your emergency copayment will not be waived.

$325 per visit

$325 per visit

Not covered:

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

All charges

All charges

We cover professional services recommended by a mental health or substance use disorder Plan provider and contained in a treatment plan that we approve. The treatment plan may include services, drugs, and supplies described elsewhere in this brochure.

Notes:

• We cover the services only when we determine that the care is clinically appropriate to treat your condition, and only when you receive the care as part of a treatment plan developed by a mental health or substance use disorder Plan provider.
• OPM will base its review of disputes about treatment plans on the treatment plan's clinical appropriateness. OPM will generally not order us to pay or provide one clinically appropriate treatment in favor of another.

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

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

Diagnosis and treatment of mental illness. Services include:

• Diagnostic evaluation
• Treatment and counseling (including individual and group therapy visits)
• Crisis intervention and stabilization for acute episodes

$25 per office visit for individual therapy

$12 per office visit for group therapy

$30 per office visit for individual therapy

$60 per office visit for group therapy

• Psychological testing necessary to determine the appropriate psychiatric treatment

$25 per office visit for individual therapy

$12 per office visit for group therapy

$30 per office visit for individual therapy

$60 per office visit for group therapy

Diagnosis and treatment of substance use disorders. Services include:

• Detoxification (medical management of withdrawal from the substance)
• Treatment and counseling (including individual and group therapy visits)

Notes:

• You may see an outpatient mental health or substance use disorder Plan provider for outpatient services without a referral from your primary care provider. See Section 3, How you get care, for information about services requiring our prior approval.
• Your mental health or substance use disorder Plan provider will develop a treatment plan to assist you in improving or maintaining your condition and functional level, or to prevent relapse and will determine which diagnostic and treatment services are appropriate for you.

$25 per office visit for individual therapy

$5 per office visit for group therapy (maximum $5 per day for substance abuse benefit)

$30 per office visit for individual therapy

$60 per office  visit for group therapy

• Medication evaluation and management

$25 per office visit

$30 per office visit

• Inpatient psychiatric or substance use disorder care
• Residential Treatment

Note: All inpatient admissions require approval by a mental health or substance use disorder Plan physician.

$650 per admission

limited to 100 days per calendar year

20% of the Plan allowance (deductible applies)

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

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

$25 per day

20% of the Plan allowance (deductible applies)

Not covered:

• Care that is not clinically appropriate for the treatment of your condition
• Inpatient services we have not approved
• Intelligence, IQ, aptitude ability, learning disorders, or interest testing not necessary to determine the appropriate treatment of psychiatric condition
• Evaluation or therapy on court order or as a condition of parole or probation, or otherwise required by the criminal justice system, unless determined by a Plan physician to be medically necessary and appropriate
• Services that are custodial in nature
• Services rendered or billed by a school or a member of its staff
• Services provided under a federal, state, or local government program
• Psychoanalysis or psychotherapy credited toward earning a degree or furtherance of education or training regardless of diagnosis or symptoms
• Inpatient services that are not part of a preauthorized approved treatment plan

All charges

All charges

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

• Drugs and medicines that by Federal law of the United States require a physician’s prescription for their purchase, except those listed as Not covered.
• Certain over-the-counter medications prescribed by a provider and listed on the Plan's formulary
• Insulin
• Diabetic supplies limited to:
  • Disposable needles and syringes for the administration of covered medications
• Growth hormones
  Growth hormone requires our prior approval. See Section 3, Services requiring our prior approval.
• Drugs for sexual dysfunction

• Compound drugs
  • For compound drugs you will be charged your applicable generic or brand name drug copayment depending on the compound drug's main ingredient, whether the main ingredient is a generic or brand name drug
  • A compound drug is one in which two or more drugs or pharmaceutical agents are combined together to meet the requirements of a prescription.
  • The Carrier does not cover compounded prescriptions unless all the ingredients are FDA approved and determined to be medically necessary

• Drugs to treat gender dysphoria
  • Drug treatment for gender dysphoria is individualized and varies. Examples of covered drugs are included below and may require prior authorization. Drug coverage is subject to change. Please consult the formulary for more information.
  • Feminizing hormone therapy: estradiol tablets or patches, estradiol valerate injection
  • Masculinizing hormone therapy: testosterone cypionate injection, testosterone enanthate injections
    
    Financial assistance programs also known as "Patient Assistance Programs," "Fee Forgiveness," "Nor Out-of-Pocket," 'Manufacturers Coupons," "Discount programs," for Specialty Drugs will not count toward your out-of-pocket maximum or deductible, if you have one.

Retail Pharmacy

Tier 1 - $15 per prescription or refill for retail generic drugs for up to 30-day supply

Tier 2 - $75 per prescription or refill for retail preferred brand-name drugs for up to 30-day supply

Tier 3 - $180 per prescription or refill for retail non-preferred brand-name drugs for up to 30-day supply

Tier 4 - 25% up to $500 per prescription or refill for a 30-day supply of covered Specialty Drugs filled through a contracted specialty pharmacy

Mail Order

Tier 1 - $30 per prescription or refill for mail-order generic drugs for up to 90-day supply

Tier 2 - $150 per prescription or refill for mail-order preferred brand-name drugs for up to 90-day supply

Tier 3 - $360 per prescription or refill for mail-order non-preferred brand-name drugs for up to 90-day supply

Tier 4 - Mail order not available for specialty medications

Note: If there is no generic equivalent available, you will still have to pay the brand name copay.

Retail Pharmacy

Tier 1 - $10 per prescription or refill for retail generic drugs for up to 30-day supply

Tier 2 - 40% up to $250 per prescription or refill for retail preferred brand-name drugs for up to 30-day supply

Tier 3 - 60% up to $350 per prescription or refill for retail non-preferred brand-name drugs for up to 30-day supply

Tier 4 - 30% up to $500 per prescription or refill for a 30-day supply of covered Specialty Drugs filled through a contracted specialty pharmacy

Mail Order

Tier 1 - $20 per prescription or refill for mail order generic drugs for up to a 90-day supply

Tier 2 - 40% coinsurance up to $500 maximum for mail order preferred brand for up to a 90-day supply

Tier 3 - 60% up to $700 maximum for mail order for non-preferred brand-name drugs for up to a 90-day supply

Tier 4 - Mail order not available for specialty medications

Note: If there is no generic equivalent available, you will still have to pay the brand name copay.

Anti-Obesity Drugs

50% of the Plan allowance

50% of the Plan allowance (deductible applies)

Contraceptive drugs and devices as listed in the Health Resources and Services Administration site https://www.hrsa.gov/womens-guidelines.

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

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

Medical Mutual offers robust coverage of contraceptive options in all categories. If a contraceptive is not covered but medically necessary, we offer a simple exceptions process. Your provider can contact Express Scripts to request the exception by calling 1-800-753-2851. If your provider agrees that a non-covered contraceptive is medical necessary, the exception will be granted, and your request will be approved for $0 coverage. 

Exception requests for Contraceptive medications will be processed within 24 hours of receiving all necessary information from your provider.

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. Medical Mutual allows online adjudication of OTC contraceptives at the pharmacy, which prevents members from having to pay out of pocket and submit for reimbursement later.

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

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

Nothing

Nothing

Fertility and Sexual dysfunction drugs

Note: Fertility drugs are limited to three cycles per year

50% of the Plan allowance

50% of the Plan allowance (deductible applies)

Prescription and over-the-counter tobacco cessation drugs approved by the FDA to treat tobacco dependence

Nothing

Nothing

Not covered

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Prescriptions filled at out-of-network pharmacies, except for out-of-area emergencies or out of area urgent care services
• Vitamins, nutrients and food supplements not listed as a covered benefit even if a physician prescribes or administers them
• Nonprescription drugs, unless they are included in our drug formulary or listed as covered above
• Medical supplies such as dressings and antiseptics, except as listed above
• Drugs used to shorten the duration of the common cold
• Any requested packaging of drugs other than the dispensing pharmacy's standard packaging Replacement of lost, stolen or damaged prescription drugs or accessories
• Drugs related to non-covered services
• Drugs for the promotion, prevention, or other treatment of hair loss or growth

All charges

All charges

Opioid Rescue Agents

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

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

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

Nothing

Nothing

The following are covered:

Preventive Medications with USPSTF A and 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: when prescribed by a healthcare professional and filled by a network pharmacy.

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

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

• Drugs and medicines that by Federal law of the United States require a physician’s prescription for their purchase, except those listed as Not covered.
• Insulin
• Diabetic supplies limited to:
  • Disposable needles and syringes for the administration of covered medications
• Drugs to treat gender dysphoria
  Drug treatment for gender dysphoria is individualized and varies. Examples of covered drugs are included below and may require prior authorization. Drug coverage is subject to change. Please consult the formulary for more information:
  • Feminizing hormone therapy: estradiol tablets or patches, estradiol valerate injection
  • Masculinizing hormone therapy: testosterone cypionate injection, testosterone enanthate injection
    
• Sexual dysfunction drugs
  
  
  

Retail Pharmacy

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

Generic Drugs: $10 per prescription or refill for retail generic drugs up to 30-day supply

Preferred Brand Name Drugs: $75 per prescription or refill for retail preferred brand-name- drugs for up to 30-day supply

Non-Preferred Brand Name Drugs: 60% up to $180 per prescription or refill for retail non-preferred brand-name drugs for up to 30-day supply 

Specialty Drugs: 25% up to $500 per prescription or refill for a 30-day supply of covered Specialty Drugs

Mail Order

Generic Drugs: $20 per prescription or refill for mail order generic drugs up to 90-day supply

Preferred Brand Name Drugs: $150 per prescription or refill for mail order preferred brand-name- drugs for up to 90-day supply

Non-Preferred Brand Name Drugs: 60% up to $360 per prescription or refill for mail order non-preferred brand-name drugs for up to 90-day supply 

Specialty Drugs: 25% up to $500 per prescription or refill for a 30-day supply of covered Specialty Drugs

Note: If there is no generic equivalent available, you will still have to pay the brand name copay.

Retail Pharmacy

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

Generic Drugs: $10 per prescription or refill for retail generic drugs up to 30-day supply

Preferred Brand Name Drugs: $75 per prescription or refill for retail preferred brand-name- drugs for up to 30-day supply

Non-Preferred Brand Name Drugs: 60% up to $180 per prescription or refill for retail non-preferred brand-name drugs for up to 30-day supply 

Specialty Drugs: 25% up to $500 per prescription or refill for a 30-day supply of covered Specialty Drugs 

Mail Order

Generic Drugs: $20 per prescription or refill for mail order generic drugs up to 90-day supply

Preferred Brand Name Drugs: $150 per prescription or refill for mail order preferred brand-name- drugs for up to 90-day supply

Non-Preferred Brand Name Drugs: 60% up to $360 per prescription or refill for mail order non-preferred brand-name drugs for up to 90 day supply 

Specialty Drugs: 25% up to $500 per prescription or refill for a 30-day supply of covered Specialty Drugs

Note: If there is no generic equivalent available, you will still have to pay the brand name copay.

Contraceptive drugs and devices as listed in the Health Resources and Services Administration site https://www.hrsa.gov/womens-guidelines.

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

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

Medical Mutual offers robust coverage of contraceptive options in all categories. If a contraceptive is not covered but medically necessary, we offer a simple exceptions process. Your provider can contact Express Scripts to request the exception by calling 1-800-753-2851. If your provider agrees that a non-covered contraceptive is medical necessary, the exception will be granted, and your request will be approved for $0 coverage.

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)

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

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

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

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

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

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

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

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

Not covered

• Drugs and supplies for cosmetic purposes
• Drugs to enhance athletic performance
• Fertility drugs
• Drugs obtained at a non-Plan pharmacy; except for out-of-area emergencies
• Nonprescription medications

All charges

All charges

The following are covered:

• Preventive Medications with a USPSTF A and 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: when prescribed by a healthcare professional and filled by a network pharmacy.

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

We cover services to promptly repair (but not replace) a sound, natural tooth, if:

• damage is due to an accidental injury from trauma to the mouth from violent contact with an external object,
• the tooth has not been restored previously, except in a proper manner, and
• the tooth has not been weakened by decay, periodontal disease or other existing dental pathology.

Note: Services will be covered only when provided within 72 hours following the accidental injury.

Nothing

Nothing

Not covered:

• Services for conditions caused by an accidental injury occurring before your eligibility date

All charges

All charges

We have no other dental benefits

Not covered

Not covered

If a new baby is on the way, download the MedMutual Maternity app. It features a variety of resources and tools to help families prepare for baby’s arrival.

Visit MedMutual.com/MaternityApp to learn more.

For pregnancies that are considered high-risk, we offer access to a registered nurse who specializes in high-risk maternity care. Call our Case Management team at 1-800-258-3175 to learn more.

Medical Mutual's wellness programs provide plan members with core initiatives designed to help them understand overall health, identify health risks and participate in a programs to improve your total well-being.

The following programs and services are available to all Medical Mutual covered plan members:

• Health Assessment
• QuitLine Tobacco Cessation Program
• Nurse Line
• Weight Watchers discount
• Fitness discounts
• Hearing discounts
• Wellness portal
• Online educational tools
• Online wellness challenges

The Health Assessment

Begin a focus on your health by completing the Health Assessment which allows you to assess you current health status. The Health Assessment is a confidential questionnaire that compiles information about your health status, current medical conditions and daily health habits to give you an overall picture of your health.
The results show current health status, potential risk for chronic health conditions, and suggestions for improving health going forward. It offers the following advantages:

• Helps you make more informed decisions about healthcare and lifestyle.
• Helps you take control of your own health.
• Prepares you for doctor's visits, including knowing what questions to ask.
• Tailors educational materials to your health status and risks.

The Health Assessment allows the Carrier to provide you with additional information on helpful programs Medical Mutual offers that can help you in the following areas:

• Nutrition
• Physical Activity
• Seat belt usage
• Stress
• Tobacco use
• Weight management

QuitLine Tobacco Cessation Program - Program participants have access to professional telephone counseling, educational materials and a supply of nicotine replacement therapy (gum or patches) at no cost.

Weight Watchers Discount - Plan members can participate in an online, at work or local meeting series and obtain a discount on the registration fees each calendar year.

Fitness Discounts - We partner with local and national fitness clubs to offer discounts on club membership fees.

Wellness Portal - Medical Mutual plan members will have access to a wellness portal providing health and wellness education, program enrollment information

You may call 888-912-0636 (TTY:771) 24 hours a day, 7 days a week for any of your health concerns. You may talk with a registered nurse who can help assess medical symptoms and provide advice over the phone, when appropriate, including directing you to urgent care.

We provide a TTY/text telephone number at: 711. Sign language services are also available.

Whether you live with a chronic condition or just found out you're pregnant, having a health coach to guide you can help improve your overall well-being. You can trust the Carrier's Chronic Condition Management and Maternity Programs to support you. Medical Mutual programs, available at no additional cost to qualified members, help members who are pregnant or diagnosed with one or more of the following conditions:

• Asthma
• Chronic Obstructive Pulmonary Disease (COPD)
• Congestive Heart Failure
• Coronary Artery Disease
• Diabetes
• MSK/Pain Management

Our chronic condition management program includes several incentives for qualified members designed to enhance participation and improve clinical outcomes.

• Active diabetes program participants receive essential diabetic testing supplies, if needed.
• Diabetic participants receive an electronic tablet and glucometer to monitor and report symptoms and track blood sugar levels
• Heart failure participants receive an electronic tablet, if needed, to monitor and report symptoms and weight.
• COPD participants receive an electronic tablet and scale, if needed, to monitor and report symptoms
• Coronary artery disease participants receive an electronic tablet and home blood pressure monitor to report symptoms and track daily readings.
• The Sword program offers qualifying members with musculoskeletal conditions such as chronic low back pain, neck and shoulder pain, and pain from most type of arthritis, with access to digital/virtual physical therapy. Qualifying patients receive easy to use technology to utilize at home that connects participants virtually with a Sword physical therapist.

Medical Mutual's Care Management staff includes nurse care managers who work closely with the plan member and family members to help choose the most appropriate facility based on the individual's specific needs. For transplant needs, our dedicated transplant team of specialized registered nurses work proactively with plan members and their health care providers to direct them to the plan's network transplant center based on the member's health care needs. These Medicare Certified Transplant centers provide solid and tissue transplant procedures throughout the State of Ohio. If it is determined that the plan member requires services that are not available within the State of Ohio, the transplant team coordinates out of state transplants utilizing a Transplant network.

In most cases, providers and facilities file claims for you. Provider must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. For claims questions and assistance, contact us at 800-315-3144 (TYY: 711), or at our website at www.MedMutual.com/PSHB.

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

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

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

Submit your claims to:

Claims Administration
Medical Mutual of Ohio
PO Box 6018
Cleveland, OH 44101-1018

Submit your claims to:

Claims Administration
Medical Mutual of Ohio
PO Box 6018
Cleveland, OH 44101-1018

Submit your claims to:

Claims Administration
Medical Mutual of Ohio
PO Box 6018
Cleveland, OH 44101-1018

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

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

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

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

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

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

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

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

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

b) Send your request to us at: Member Appeals, Medical Mutual, PO Box 94580, Cleveland, OH 44101-4580; and

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

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

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

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

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

a) Pay the claim or

b) Write to you and maintain our denial or.

c) Ask you or your provider for more information

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

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

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

You must write to OPM within:

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

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Postal Service Insurance Operations (PSIO), 1900 E Street, room 3443, NW, Washington, DC 20415-3630.

Send OPM the following information:

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

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

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

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

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

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

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

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

Note: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call us at 800-315-3144. We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal. You may call OPM’s PSIO at 202-936-0002 between 8 a.m. and 5 p.m. Eastern Time.

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

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

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

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

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

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

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

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

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

We do not cover services that:

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

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

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

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

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

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

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

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

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

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

If you are a participant in a clinical trial, this health plan will provide related care as follows, if it is not provided by the clinical trial:

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

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

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

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

For more information on these requirements, please contact 800-315-3144 (TTY: 711).

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 800-315-3144 (TTY: 711) or see our website at www.MedMutual.com/PSHB.

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

Please review the following table. It illustrates your cost share if you are enrolled in Medicare Part B. Medicare will be primary for all Medicare eligible services. Members must use providers who accept Medicare's assignment.

Compare for STANDARD and BASIC Option

Benefit: Out of Pocket Maximum

Member Cost STANDARD Option without Medicare: $6,000/$12,000
Member Cost STANDARD Option with Medicare parts A and B: $6,000/$12,000
Member Cost BASIC Option without Medicare: $6,500/$13,000
Member Cost BASIC Option with Medicare parts A and B: $6,500/$13,000

Benefit: Primary Care

Member Cost STANDARD Option without Medicare: $25
Member Cost STANDARD Option with Medicare parts A and B: $25
Member Cost BASIC Option without Medicare: $30
Member Cost BASIC Option with Medicare parts A and B: $30

Benefit: Specialist

Member Cost STANDARD Option without Medicare: $45
Member Cost STANDARD Option with Medicare parts A and B: $45
Member Cost BASIC Option without Medicare: $60
Member Cost BASIC Option with Medicare parts A and B: $60

Benefit: Inpatient Hospital

Member Cost STANDARD Option without Medicare: $650
Member Cost STANDARD Option with Medicare parts A and B: $650
Member Cost BASIC Option without Medicare: 20% after deductible
Member Cost BASIC Option with Medicare parts A and B: 20% after deductible

Benefit: Outpatient Surgery

Member Cost STANDARD Option without Medicare: $375
Member Cost STANDARD Option with Medicare parts A and B: $375
Member Cost BASIC Option without Medicare: 20% after deductible
Member Cost BASIC Option with Medicare parts A and B: 20% after deductible

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

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

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

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

This Plan and our PSHB Medicare Advantage plan:

You may enroll in our Medicare Advantage plan and remain enrolled in our PSHB plan. For more information regarding our PSHB Medicare Advantage Plan, please contact 1-800-801-4823 (TTY: 711). Customer Care specialists are available to answer your call from 8 a.m. to 8 p.m. EST, seven days a week from October 1 to March 31 (except Thanksgiving and Christmas) and 8 a.m. to 8 p.m. EST Monday through Friday from April 1 to September 30 (except holidays)

The PSHB Medicare Advantage Plan offers enhancements to your PSHB plan by waiving your cost shares for many services and adding extra benefits for no additional cost. Enrollment in our PHSB Medicare Advantage plan is voluntary.

Below is a Summary of the benefits available on the PSHB plans we offer, you will be able to compare the plan options by reviewing the highlights for each plan listed.

Compare PSHB Standard Option, Basic Option & PSHB Medicare Advantage Option.

Benefit: Out of Pocket Maximum

Member Cost STANDARD Option without Medicare: $6,000/$12,000
Member Cost STANDARD Option & PDP - Medicare parts A and B: $6,000/$ 12,000
Member Cost BASIC Option without Medicare: $6,500/$ 13,000
Member Cost BASIC Option & PDP -Medicare parts A and B: $6,500/$ 13,000
Member Cost PSHB Medicare Advantage Option – Medicare parts A and B: Not Applicable since we are waiving the medical cost shares on this plan option.

Benefit: Primary Care

Member Cost STANDARD Option without Medicare: $25
Member Cost STANDARD Option with PDP - Medicare parts A and B: $25
Member Cost BASIC Option without Medicare: $30
Member Cost BASIC Option with PDP - Medicare parts A and B: $30
Member Cost PSHB Medicare Advantage Option – Medicare parts A and B: $0

Benefit: Specialist

Member Cost STANDARD Option without Medicare: $45
Member Cost STANDARD Option with PDP -  Medicare parts A and B: $45
Member Cost BASIC Option without Medicare: $60
Member Cost BASIC Option with PDP - Medicare parts A and B: $60
Member Cost PSHB Medicare Advantage Option – Medicare parts A and B: $0

Benefit: Medicare Advantage Prescription Drugs

Member Cost STANDARD Option for Generic Drugs Retail: $10
Member Cost STANDARD Option for Preferred Brand Name Drugs Retail: $75
Member Cost STANDARD Option for Non-Preferred Brand Name Drugs Retail: 60% up to $180
Member Cost STANDARD Option for Specialty Drugs Retail: 25% up to $500
Member Cost STANDARD Option for Generic Drugs Mail Order: $20
Member Cost STANDARD Option for Preferred Brand Name Drugs Mail Order: $150
Member Cost STANDARD Option for Non-Preferred Brand Name Drugs Mail Order: 60% up to $360
Member Cost STANDARD Option for Specialty Drugs Mail Order: 25% up to $500

Member Cost BASIC Option for Generic Drugs Retail: $10
Member Cost BASIC Option for Preferred Brand Name Drugs Retail: $75
Member Cost BASIC Option for Non-Preferred Brand Name Drugs Retail: 60% up to $180
Member Cost BASIC Option for Specialty Drugs Retail: 25% up to $500
Member Cost BASIC Option for Generic Drugs Mail Order: $20
Member Cost BASIC Option for Preferred Brand Name Drugs Mail Order: $150
Member Cost BASIC Option for Non-Preferred Brand Name Drugs Mail Order: 60% up to $360
Member Cost BASIC Option for Specialty Drugs Mail Order: 25% up to $500

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 Medicare Part A and/or Part B, and are not enrolled in our Medicare Advantage Prescription Drug Plan (MAPD), you will be automatically group enrolled into our Medicare PDP EGWP. Our PDP EGWP is a prescription drug benefit for Postal Service annuitants and their covered Medicare-eligible family members. This allows you to receive benefits that will never be less than the standard prescription drug coverage that is available to members with non-PDP EGWP prescription drug coverage. But more often you will receive benefits that are better than members with standard non-PDP EGWP prescription drug coverage. Note: You have the choice to opt out of or disenroll from our PDP EGWP at any time and may obtain prescription drug coverage outside of the PSHB Program.

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

Members with higher incomes may have a separate premium payment for their Medicare Part D Prescription Drug Plan (PDP) benefit. Please refer to the Part D-IRMAA section of the Medicare website: https://www.medicare.gov/drug-coverage-part-d/costs-for-medicare-drug-coverage/monthly-premium-for-drug-plans to see if you would be subject to an additional premium.

For people with limited income and resources, Extra Help is a Medicare program to help with Medicare prescription drug plan costs.  Information regarding this program is available through the Social Security Administration (SSA) online at www.socialsecurity.gov , or call the SSA at 800-772-1213  TTY 800-325-0778.  You may also contact 800-801-4823 (TTY: 711).

Warning:  If you opt out of or disenroll from our PDP EGWP, you will not have any PSHB Program prescription drug coverage.  However, you can enroll in our MAPD during Open Season or for a qualifying life event (QLE) and receive PSHB Program Prescription Drug Coverage. 

The PDP EGWP opt out process:

If you were automatically group enrolled into the Express Scripts Medicare PDP EGWP and choose to opt out you can request that you not be enrolled by notifying Benistar Admin. Services, Inc., which is administering and servicing various aspects of your Express Scripts Medicare PDP EGWP prescription drug coverage. You can notify Benistar Admin. Services, Inc. Retiree Customer Service Center at 1-800-236-4782, Monday through Friday, 8:30 a.m. through 5:30 p.m., Eastern Time. TTY users should call 711.

What happens if I opt out of Express Scripts Medicare PDP EGWP enrollment?

Important: Keep in mind that if you leave our plan and don’t have or get other Medicare prescription drug coverage or creditable coverage (as good as Medicare’s), you may be required to pay a late enrollment penalty (LEP) if you go 63 days or more without Medicare Part D coverage or other creditable prescription drug coverage.

If you choose not to be enrolled in this plan, you can join a new Medicare prescription drug plan or Medicare health plan outside of your former employer’s plan from October 15 to December 7. Except in special cases, you cannot join a new plan at any other time of the year. You can, however, join or leave a plan at any time if Medicare decides that you need Extra Help with paying the plan costs. If Medicare decides that you no longer need Extra Help, you will have two months to make changes after Medicare notifies you of its decision. You can call 1.800.MEDICARE (1-800-633-4227), 24 hours a day, 7 days a week for assistance. TTY users should call 1-877-486-2048.

Whom should I contact if I have questions?

If you have questions about the Express Scripts Medicare PDP EGWP plan, please review your plan documents or contact Benistar Admin. Services, Inc. Retiree Customer Service Center at 1-800-236-4782, Monday through Friday, 8:30 a.m. through 5:30 p.m., Eastern Time.  TTY users should call 711.

The PDP EGWP disenrollment process:

When you are enrolled in the Express Scripts Medicare PDP EGWP, you may choose to disenroll at any time.

Whom should I contact if I have questions?

If you would like to disenroll from the Express Scripts Medicare PDP EGWP plan, please contact the Benistar Admin. Services, Inc. Retiree Customer Service Center at 1.800.236.4782, Monday through Friday, 8:30 a.m. through 5:30 p.m., Eastern Time. TTY users should call 711.

If you have already joined another Medicare prescription drug plan (or a Medicare Advantage Plan with prescription drug coverage), you should have received a confirmation letter. If you have not joined another Medicare plan, you should think about doing so. If you do not enroll in a new plan at this time or you do not have or obtain creditable prescription drug coverage (as good as Medicare’s) for 63 days or more, you may have to pay a late enrollment penalty if you enroll in Medicare prescription drug coverage in the future.

General Medicare enrollment/disenrollment guidelines Remember that you can generally enroll in and disenroll from a Medicare prescription drug plan only at certain times during the year. If you meet certain special exceptions, such as if you qualify for Extra Help in paying for your prescription drug costs (see below), you may enroll in a new plan at any time during the year. Otherwise, you can only enroll in a plan, disenroll from a plan or switch plans between October 15 and December 7 of each year.

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 during Open Season or for a QLE.   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 the Benistar Admin. Services, Inc. Retiree Customer Service Center at 1.800.236.4782, Monday through Friday, 8:30 a.m. through 5:30 p.m., Eastern Time. TTY users should call 711.

• 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 reviewed by the Food and Drug Administration; or is a drug trial that is exempt from the requirement of an investigational new drug application.

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

Coinsurance is the percentage of our allowance that you must pay for your care. See Section 4.

A copayment is a fixed amount of money you pay when you receive covered services. See Section 4.

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. 

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

(1) Assistance with activities of daily living, for example, walking, getting in and out of bed, dressing, feeding, toileting, and taking medicine. (2) Care that can be performed safely and effectively by people who, in order to provide the care, do not require medical licenses or certificates, or the presence of a supervising licensed nurse. Custodial care that last 90 days or more is sometimes known as long term care.

A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for those services. See Section 4.

We do not cover a service, supply, item, or drug that we consider experimental. We consider a service, supply, item, or drug to be experimental when the service, supply, item or drug:

1. has not been approved by the FDA; or
2. is the subject of a new drug or new device application on file with the FDA; or
3. is part of a Phase I or Phase II clinical trial, as the experimental or research arm of a Phase III clinical trial; or is intended to evaluate the safety, toxicity, or efficacy of the service; or
4. is available as the result of a written protocol that evaluates the service's safety, toxicity, or efficacy; or
5. is subject to the approval or review of an Institutional Review Board; or
6. requires an informed consent that describes the service as experimental or investigational.

We carefully evaluate whether a particular therapy is safe and effective or offers a reasonable degree of promise with respect to improving health outcomes. The primary source of evidence about health outcomes of any intervention is peer-reviewed medical or dental literature.

Health care benefits that are available as a result of your employment, or the employment of your spouse, and that are offered by an employer or through membership in an employee organization. Health care coverage may be insured or indemnity coverage, self-insured or self-funded coverage, or coverage through health maintenance organizations or other managed care plans. Health care coverage purchased through membership in an organization is also "group health coverage."

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

All benefits need to be medically necessary in order for them to be covered benefits. Generally, if your Plan physician provides the service in accord with the terms of this brochure, it will be considered medically necessary. However, some services are reviewed in advance of you receiving them to determine if they are medically necessary. When we review a service to determine if it is medically necessary, a Plan physician will evaluate what would happen to you if you do not receive the service. If not receiving the service would adversely affect your health, it will be considered medically necessary. The services must be a medically appropriate course of treatment for your condition. If they are not medically necessary, we will not cover the services. In case of emergency services, the services that you received will be evaluated to determine if they were medically necessary.

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.

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

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

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

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

An unexpected bill you receive for:

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

Us and We refer to Medical Mutual.

You refers to the enrollee and each covered family member.

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

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

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

If you believe your claim qualifies as an urgent care claim, please contact our Customer Service Department at 800-315-3144 (TTY: 711). 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.

$25 per primary care office visit
$45 per specialty care office visit

27

$650 per admission

53

$375 per outpatient surgery

54

$325 per visit

58

$325 per visit

58

Regular cost-sharing.

60-62

Retail Pharmacy

• Tier 1 - Generic Drugs: - $10 per prescription or refill
• Tier 2 - Preferred Brand Name Drugs: $75 per prescription or refill
• Tier 3 - Non-Preferred Brand Name Drugs: 60% with a maximum of a $180 copayment per prescription or refill
• Tier 4 - Specialty Drugs (through a contracted specialty pharmacy): 25% with a maximum of a $500 copayment

Mail Order

• Tier 1 - Generic Drugs: $20 per prescription or refill
• Tier 2- Preferred Brand Name Drugs: $150 per prescription or refill
• Tier 3- Non-Preferred Brand Name Drugs: 60% with a maximum of a $360 copayment per prescription or refill
• Tier 4 - Specialty Drugs: Not applicable or available

65-69

Tier 1 - $30 per prescription or refill for mail-order generic drugs for up to 90-day supply

Tier 2- $150 per prescription or refill for mail-order preferred brand-name drugs for up to 90-day supply

Tier 3- $360 per prescription or refill for mail-order non-preferred brand-name drugs for up to 90-day supply

Tier 4- Mail order not available for Specialty medications

65-69

No benefit. Except for Accidental Injury to teeth

74

Refractions;

$25 per primary care office visit

$45 per specialty care office visit

38

24/7 Nurse Line; Centers of Excellence; Services for the deaf, hard or hearing or speech impaired, Wellness, Disease and Maternity Management

75-77

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

22-23

$30 per primary care office visit
$60 per specialty care office visit

27

20% after deductible
20% after deductible

53

54

$325 per visit
$325 per visit

58

Regular cost-sharing

60-62

Retail Pharmacy

• Tier 1 - Generic Drugs: - $10 per prescription or refill
• Tier 2 - Preferred Brand Name Drugs: $75 per prescription or refill
• Tier 3 - Non-Preferred Brand Name Drugs: 60% with a maximum of a $180 copayment per prescription or refill
• Tier 4 - Specialty Drugs (through a contracted specialty pharmacy): 25% with a maximum of a $500 copayment

Mail Order

• Tier 1 - Generic Drugs: $20 per prescription or refill
• Tier 2- Preferred Brand Name Drugs: $150 per prescription or refill
• Tier 3- Non-Preferred Brand Name Drugs: 60% with a maximum of a $360 copayment per prescription or refill
• Tier 4 - Specialty Drugs: Not applicable or available

65-69

No benefit. Except for Accidental Injury to teeth

74

Refractions;

$30 per primary care office visit

$60 per specialty care office visit

38

24/7 Nurse Line; Centers of Excellence; Services for the deaf, hard or hearing or speech impaired, Wellness, Disease and Maternity Management

75-77

Nothing after $6,500/Self Only or $13,000/per Self Plus One or Self and Family enrollment per year. Some costs do not count toward this protection.

22-23