Minimum essential coverage (MEC)

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.

Where you can get information about enrolling in the FEHB Program

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

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

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

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

We don’t determine who is eligible for coverage and, in most cases, cannot change your enrollment status without information from your employing or retirement office.  For information on your premium deductions, you must also contact your employing retirement office.

• Types of coverage available for you and your family

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

If you have a Self Only enrollment, you may change to a Self Plus One or Self and Family enrollment if you marry, give birth, or add a child to your family. You may change your enrollment 31 days before to 60 days after that event.

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

Your employing or retirement office will not notify you when a family member is no longer eligible to receive benefits, nor will we. Please tell us immediately of changes in family member status including your marriage, divorce, annulment, or when your child reaches age 26.

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

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

• Family member coverage

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

Children’s Equity Act

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

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

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

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

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

When benefits and premiums start

The benefits in this brochure are effective January 1. If you joined this Plan during Open Season, your coverage begins on the first day of your first pay period that starts on or after January 1. If you changed plans or plan options during Open Season and you receive care between January 1 and the effective date of coverage under your new plan or option, your claims will be processed according to the 2021 benefits of your prior plan or option. If you have met (or pay cost-sharing that results in your meeting) the out-of-pocket maximum under the prior plan or option, you will not pay cost-sharing for services covered between January 1 and the effective date of coverage under your new plan or option. However, if your prior plan left the FEHB Program at the end of the year, you are covered under that plan’s 2020 benefits until the effective date of your coverage with your new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any other time during the year, your employing office will tell you the effective date of coverage.

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

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

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

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

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

Upon divorce

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

Temporary Continuation of Coverage (TCC)

If you leave Federal service, Tribal employment, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary Continuation of Coverage (TCC). The Affordable Care Act (ACA) did not elmininate TCC or change the TCC rules. For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire, if you lose your Federal  or Tribal job, if you are a covered dependent child and you turn 26.  You may not elect TCC if you are fired from your Federal or Tribal job due to gross misconduct.

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

Alternatively, you can buy coverage through the Health Insurance Marketplace where, depending on your income, you could be eligible for a new kind of 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 FEHBP coverage.

We also want to inform you that the Patient Protection and ACA did not eliminate TCC or change the TCC rules.

Converting to individual coverage

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

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

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

Your benefits and rates will differ from those under the FEHB Program; however, you will not have to answer questions about your health, a waiting period will not be imposed, and your coverage will not be limited due to pre-existing conditions. When you contact us, we will assist you in obtaining information about health benefits coverage inside or outside the Affordable Care Act's Health Insurance Marketplace in your state. For assistance in finding coverage, please contact us at 800-356-2219 or visit our website at www.phs.org.

Health Insurance Marketplace

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 provide up-to-date information on the Marketplace.

We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your electronic enrollment system (such as Employee Express) confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 505-923-5678 or 800-356-2219 or TTY for the hearing impaired at 711 or toll-free at 800-659-8331. You may write to us at P.O. Box 27489, Albuquerque, NM  87125 You may also request replacement cards through our Website: www.phs.org/fehb.

Where you get covered care

You get care from “Plan providers” and “Plan facilities.” You will only pay copays and/or coinsurance.

Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential Plan providers according to national standards. We obtain, verify, review, and evaluate practitioners’ competencies and qualifications on an ongoing basis to determine whether they can participate as providers in our Plan. Providers we credential include medical doctors, specialists, physician assistants, certified nurse practitioners, licensed social workers, and licensed professional counselors.

As our Member, you must carefully follow all procedures and conditions for obtaining care from In-network specialists and/or Out-of-network Practitioners/Providers.  We no longer require a paper referral from your Primary Care Physician (PCP) for your visits to specialists.  However, it is important to your health care that your PCP is included in the decisions about the specialists that you visit.  Your PCP continues to be your partner for good health and is the best person to help you determine your needs for specialty care.

Please note that some specialists may require written referral even though we do not.  Certain procedures require Prior Authorization.  Your In-network Practitioner/Provider must obtain this Prior Authorization before providing these services to you.

What you must do to get covered care

It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since your primary care physician provides or arranges for most of your health care. You must select a primary care physician from the PHP provider directory. Locations and phone numbers of the participating doctors are listed in the PHP provider directory or can be obtained by calling the Presbyterian Customer Service Center at 505-923-5678 or 800-356-2219 or TTY for the hearing impaired at 711 or toll-free at 800-659-8331 or by accessing our website at www.phs.org/fehb. By selecting a PCP who belongs to the plan, members are selecting their corresponding network of specialists, hospitals, and other providers to serve their healthcare needs.

Your primary care physician can be a family practice, general practice, internal medicine, pediatrics, and OB/GYN (if applicable) acting as a primary care physician. Your primary care physician will provide most of your health care.

• You may receive specialty services from Plan providers without a referral.
• Even though you may see a specialist without referral, certain procedures and services may require prior authorization by Presbyterian Health Plan.
• Services of a non-Plan provider will not be covered unless precertification is obtained prior to receiving the services. You may be liable for charges resulting from failure to obtain precertification for services provided by the non-Plan physician, except for urgent or emergent services.
• If you are seeing a specialist and your specialist leaves the Plan, call us to assist You in finding another specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.
• If you have a chronic and disabling condition and lose access to your specialist because we:
  • terminate our contract with your specialist for other than cause; or
  • drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB program plan; or
  • reduce our service area and you enroll in another FEHB plan.

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

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

• If you are hospitalized when your enrollment begins

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 Center immediately at 800-356-2219 or 505-923-5678 or TTY for the hearing impaired at 711 or 800-659-8331. If you are new to the FEHB Program, we will arrange for you to receive and provide benefits for your covered services while you are in the hospital beginning on the effective date of your coverage.

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

• you are discharged, not merely moved to an alternative care center; or
• the day your benefits from your former plan run out; or
• the 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 FEHB 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.

• Inpatient hospital admission

• Other services

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

Certain services require approval from us.  Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice.

We call this review and approval process pre-authorization.  Your physician must obtain pre-authorization for services such as, but not limited to: Durable Medical Equipment, Hospice, Acute Rehabilitation, Outpatient Rehab, Skilled Nursing Facilities, Hospitalization and Mental Health/Substance Abuse care.

First, your physician, your hospital, you, or your representative must call us at 800-356-2219 or 505-923-5678 or TTY for the hearing impaired at 711 or 800-659-8331 before admission or services requiring prior authorization are rendered. 

Next, provide the following information:

• enrollee’s name and Plan identification;
• 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.

• Non-urgent care claims

For non-urgent 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 45 days from the receipt of the notice to provide the information.

• Urgent care claims

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 the required information.  We will make our decision on the claim within 48 hours of (1) the time we received the additional information or (2) the end of the time frame, whichever is earlier.

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

You may request that your urgent care claim on appeal be reviewed simultaneously by us and OPM.  Please let us know that you would like a simultaneous review of your urgent care claim by OPM either in writing at the time you appeal our initial decision, or by calling us toll-free at 800-356-2219.  For the hearing impaired, call our TTY line at 711 or toll-free at 800-659-8331.  You may also call OPM’s Health Insurance 3 at 202-606-0737 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review.  We will cooperate with OPM so they can quickly review your claim on appeal.  In addition, if you did not indicate that your claim was a claim for urgent care, call us toll-free at 800-356-2219.  For the hearing impaired, call our TTY line at 711 or toll-free at 800-659-8331.  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).

• Concurrent care claims

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.

The Federal Flexible Spending Account Program – FSAFEDS

• Health Care FSA (HCFSA) – Reimburses you for eligible out-of-pocket health care expenses (such as copays, deductibles,  physician prescribed over-the-counter drugs and medications, vision and dental expenses, and much more) for you and your tax dependents, including adult children (through the end of the calendar year in which they turn 26).
• FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB and FEDVIP plans. This means that when you or your provider files claims with your FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-pocket expenses based on the claim information it receives from your plan.

• Emergency inpatient admission

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

• Maternity care

You do not need to precertify 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 caesarean section, then you, your representative, your physician or the hospital must contact us on precertification of additional days.  Further, if your baby stays after you are discharged, your representative, your physician or the hospital must contact us for precertification of additional days for your baby.

• If your treatment needs to be extended

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.

Certain services require approval from us. Before giving approval, we consider if the service is covered, medically necessary, and follows generally accepted medical practice.

We call this review and approval process pre-authorization. Your physician must obtain pre-authorization for services such as, but not limited to: Durable Medical Equipment, Hospice, Acute Rehabilitation, Outpatient Rehab, Skilled Nursing Facilities, Hospitalization and Mental Health/Substance Abuse care.

Except in a medical emergency you must obtain pre-authorization prior to seeing a non-Plan physician. Your Plan physician must get our approval before sending you to a hospital. If required medical services are not available from Plan providers, your Plan physician must request and obtain written authorization from the Presbyterian Health Plan Medical Director before you may receive services.

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.

• To reconsider a non-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.

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

1. Precertify your hospital stay or if applicable, arrange for the health care provider to give you the care or grant your request for prior approval for a service, drug, or supply; or

2. Ask you or your provider for more information.

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

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

3. Write to you and maintain our denial.

• To reconsider an urgent care claim

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 consideration request.  We will expedite the review process, which allows oral or written requests for appeals and the exchange of information by phone, electronic mail, facsimile, or other expeditious methods.

• To file an appeal with OPM

Cost-sharing

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

Copays

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

Example: High option, when you see your primary care physician for non-preventive services. you pay a copay of $25 per office visit, and when you go see a specialist, you pay a copay of $40 per office visit. When you see your primary care physician for preventive services, you pay nothing for the office visit and when you go see a specialist, you pay a copay of $40 for adult and $20 for children per office visit. When you go in the hospital, you pay $100 copay per day up to 5 days per admission.

Deductible

A deductible is a fixed expense you must incur for certain covered services and supplies before the plan starts paying benefits.  Copays do not count toward any deductible.

• This High Option HMO plan does not have a deductible.
• The calendar year deductible is $500 per person under the Standard Option and $2,000 under the Wellness Option plan.  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 $500 under Standard Option and $2,000 under the Wellness Option plan.  Under a Self Plus One or Self and Family 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 $1,000 under the Standard Option and $4,000 under the Wellness Option. 

Note:  If you change plans during Open Season, you do not have to start a new deductible under your prior plan between January 1 and the effective date of your new plan.  If you change plans at another time during the year, you must begin a new deductible under your new plan.

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

Coinsurance is the percentage of our negotiated fee (plan allowance) that you must pay for your care.

Example: In our Plan, you pay 50% of our negotiated fee (plan allowance) for infertility services and 30% of our negotiated fee (plan allowance) for durable medical equipment.

Your catastrophic protection out-of-pocket maximum

After your (copays and coinsurance) total $6,350 for self only or $12,700 for Self Plus One or Self and Family enrollment under the High and Standard Options and $8,150 for self only or $16,300 for Self Plus One or Self and Family enrollment for the Wellness Option in any Calendar year, You do not have to pay any more for Covered services.  However, copays and/or coinsurance for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay copays and/or coinsurance for these services:

• Dental services
• Vision services
• Non-covered charges

Be sure to keep accurate records of your copays and/or coinsurance since you are responsible for informing us when you reach the maximum.

Facilities of the Department of Veterans Affairs, the Department of Defense and the Indian Health Services are entitled to see 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 for certain services and charges.  Contact the government facility directly for more information.

Flexible benefits option

Under the flexible benefits option, we determine the most effective way to provide services.

• We may identify medically appropriate alternatives to regular contract benefits as a less costly alternative. If we identify a less costly alternative benefit, we will ask you to sign an alternative benefits agreement that will include all of the following terms in addition to other terms as necessary. Until you sign and return the agreement, regular contract benefits will continue.
• Alternative benefits will be made available for a limited time period and are subject to our ongoing review. You must cooperate with the review process.
• By approving an alternative benefit, we do not guarantee you will get it in the future.
• The decision to offer an alternative benefit is solely ours, and we may withdraw it at any time and resume regular contract benefits.
• If you sign the agreement, we will provide the agreed-upon alternative benefits for the stated time period (unless circumstances change). You may request an extension of the time period, but regular contract benefits will resume if we do not approve your request.
• Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. However, if at the time we make a decision regarding alternative benefits, we also decide that regular contract benefits are not payable, then you may dispute our regular contract benefits decision under the OPM disputed claim process (see Section 8).

For any of your health concerns, 24 hours a day, 7 days a week, you may call 505-923-5570 or toll-free at 866-221-9679. and talk with a registered nurse who will discuss treatment options and answer your health questions. For the hearing impaired, call our TTY line at 711 or 800-659-8331. The PresRN Line is confidential. You will be asked to provide some basic information to ensure that you are part of the Presbyterian Health Plan. There is no limit to the number of calls you can make.

Contact our Customer Service Center at 711 or toll-free at 800-659-8331.

• PRESious Beginnings is a statewide program that determines high-risk pregnancies and offers care management, literature and use of videos. Peri-Natal nurses are available for questions Monday through Friday 8:30 a.m. to 5:00 p.m. to assist with high-risk pregnancy questions. For additional information, call 505-724-6500
• Doula services are available for Members who deliver at Presbyterian Hospital. For more information, call 505-724-6500.

Preventive Vision Exam and Discounts

One preventive vision exam per year for adults and children and no charge on the High Option only. Discounts also available.  Please visit Presbyterian Vision administered by Versant Health under the Davis Vision Network at www.davisvision.com for further information.

Clinical Trials

Routine patient care costs that are incurred as a result of participation in a Cancer Clinical Trial in New Mexico are Covered.

Routine patient care costs mean:

• Medical services or treatment that is a benefit under this health plan that would  be Covered if the patient were receiving standard cancer treatment; or
• A drug provided to a patient during a Cancer Clinical Trial if the drug has been approved by the Federal Food and Drug Administration, whether or not that organization has approved the drug for use in treating the patient’s particular condition, but only to the extent that the drug is not paid for by the manufacturer, distributor or provider of the drug.

Routine patient care costs are Covered for Members in a Cancer Clinical Trial if:

• The Cancer Clinical Trial is undertaken for the purposes of the prevention of or the prevention of reoccurrence, early detection, or treatment of cancer for which no equally or more effective standard cancer treatment exists.
• The Cancer Clinical Trial is not designed exclusively to test toxicity or disease pathophysiology and it has a therapeutic intent.
• The Cancer Clinical Trial is being provided in New Mexico as part of a scientific study of a new therapy or intervention.
• There is not a non-Investigational treatment equivalent to the Cancer Clinical Trial.
• There is a reasonable expectation shown in clinical or pre-clinical data that the Cancer Clinical Trial will be at least as efficacious as any non-Investigational alternative.
• There is a reasonable expectation based on clinical data that the medical treatment provided in the Cancer Clinical Trial will be at least as effective as any other medical treatment.
• Pursuant to the patient informed consent, Presbyterian is not liable for damages associated with the treatment provided during any phase of a Cancer Clinical Trial.

The Clinical Trial Test must be conducted with the approval of a federal organization such as National Institutes of Health or the FDA.

• If services are not available from a Participating Provider/Practitioner, PHP will Cover services of a Non-Participating Provider/Practitioner only if the Provider/Practitioner agrees to accept PHP’s normal reimbursement for similar services, and services are provided in New Mexico.
• Any care related to the Clinical Trial Test that is investigational requires Benefit Certification by PHP. Those medical services that are not investigational such as lab and X-ray services would require Preauthorization as identified in this Section 3.

Exclusions:

• Any Cancer Clinical Trials provided outside of New Mexico as well as, those that do not meet the requirements indicated above.
• Costs of the Clinical Trial that is customarily paid for by government, biotechnical, pharmaceutical or medical device industry sources.
• Services from Non-Participating Providers/Practitioners, unless services from a Participating Provider/Practitioner are not available. Any Non-Participating services must be Preauthorized by PHP and provided for in New Mexico. The cost of a non-FDA-approved investigational drug, device or procedure.
• The cost of a non-healthcare service that the patient is required to receive as a result of participation in the Cancer Clinical Trial.
• Cost associated with managing the research that is associated with the Cancer Clinical Trial.
• Costs that would not be Covered if non-investigational treatments were provided.
• Cost of tests that are necessary for the research of the Clinical Trial.
• Costs paid or not charged for by the Cancer Clinical Trial Providers.

Video Visits

Video Visits is an alternative access point for members to receive care for non-urgent medical issues such as upper respiratory infections, flu, cold, cough, and allergies. For more information, please see page 27.

Pharmacy Cost Calculator

Members may utilize the Pharmacy Cost Calculator to look up prescriptions, determine coverage, copays, and locate participating pharmacies.  This tool can be accessed at www.phs.org/fehb.

Medical and hospital benefits

In most cases, providers and facilities file claims for you. Providers must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. For claims questions and assistance, contact us at 505-923-5678 or toll-free at 800-356-2219 or for the hearing impaired at 505-923-5699 or toll-free at 877-298-7407, or at our Web site at www.phs.org/fehb.

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 payer – such as the Medicare Summary Notice (MSN); and
• Receipts, if you paid for your services.
• For emergency or urgent care services outside the United States you are responsible for ensuring that claims are appropriately translated and that the monetary exchange, on the date of service, is clearly identified when submitting claims.

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

Submit your claims to: 

Presbyterian Health Plan
P.O. Box 27489
Albuquerque, NM 87125-7489

If a charge is made to you for covered pharmacy benefits, you must provide proof of such charge with a copy of the pharmacy receipt with the name of the drug, quantity dispensed, and National Drug Code (NDC) number.  Any charge shall be paid only upon receipt of proof satisfactory to the Plan of the occurrence, character and extent of the event and services for which claim is made.

Submit your claims to:

Presbyterian Health Plan
Attn: Pharmacy
P.O. Box 27489
Albuquerque , NM 87125-7489

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.

Notice Requirements

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

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

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

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

b) Send your request to us at: P.O. Box 27489 Albuquerque, NM 87125-7489 ; 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 and 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.

3

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

You must write to OPM within:

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

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, FEHB 3, 1900 E Street, NW, Washington, DC 20415-3630.

Send OPM the following information:

• A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;
• Copies of documents that support your claim, such as physician’s 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 the right to file a disputed claim with OPM.  Parties acting as your representative, such as medical providers, must include a copy of your specific written consent with the review request.  However, for urgent care claims, a health care professional with knowledge of your medical condition may act as your authorized representative without your express consent.

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

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

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

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

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

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

When you have double coverage, one plan normally pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the secondary payer. 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.phs.org/fehb.

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

• TRICARE and CHAMPVA

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

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

• Workers' Compensation

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.
• Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your care.

• Medicaid

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

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

When other Government agencies are responsible for your care

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

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

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

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

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

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

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

When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) coverage

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

Clinical Trials

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 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.  These costs are covered by this plan.
• Extra care costs – cost related to taking part in a clinical trial such as additional tests that a patient may need as part of the trial, but not part of the patient’s routine care.  (a) This plan covers some of these costs, providing the plan determines the services are medically necessary.  For more specific information see page 72.  We encourage you to contact the plan to discuss specific services if you participate in a clinical trial.

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 clinical trials.  This plan does not cover these costs.

When you have Medicare

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

• The Original Medicare Plan (Part A or Part B)

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. You will not need to do anything. To find out if you need to do something to file your claim, call us at 800-356-2219 or see our Website at www.phs.org/fehb.

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

• Medical services and supplies provided by physicians and other health care professionals.

We do not waive any costs if the Original Medicare Plan is your Primary Payor.

If you purchase Medicare Part B, your provider is in our network and participates in Medicare, then we waive some costs because Medicare will be the primary payor.

Benefit Description: Deductible
High Option You Pay Without Medicare: $0
High Option You Pay With Medicare Part B: $0
Standard Option You Pay Without Medicare: $500 self only/$1,000 family
Standard Option You Pay With Medicare Part B: $500 self only/$1,000 family
Wellness Option You Pay Without Medicare:  $2,000
Wellness Option You Pay With Medicare Part B: $2,000

Benefit Description: Out-of-Pocket Maximum
High Option You Pay Without Medicare: $6,350 self only/$12,700 family
High Option You Pay With Medicare Part B: $6,350 self only/$12,700 family
Standard Option You Pay Without Medicare: $6,350 self only/$12,700 family
Standard Option You Pay With Medicare Part B: $6,350 self only/$12,700 family
Wellness Option You Pay Without Medicare: $8,150 self only/ $16,300 family
Wellness Option You Pay With Medicare Part B:  $8,150 self only/ $16,300 family

Benefit Description: Part B Reimbursement Offered
High Option You Pay Without Medicare: N/A
High Option You Pay With Medicare Part B: N/A
Standard Option You Pay Without Medicare: N/A
Standard Option You Pay With Medicare Part B: N/A
Wellness Option You Pay Without Medicare: N/A
Wellness Option You Pay With Medicare Part B: N/A

Benefit Description: Primary Care Physician
High Option You Pay Without Medicare: $25
High Option You Pay With Medicare Part B: $0
Standard Option You Pay Without Medicare: $30 copay
Standard Option You Pay With Medicare Part B: $0
Wellness Option You Pay Without Medicare: First 4 visits: $20 copay, subsequent visits 30% coinsurance
Wellness Option You Pay With Medicare Part B: $0

Benefit Description: Specialist
High Option You Pay Without Medicare: $40
High Option You Pay With Medicare Part B: $0
Standard Option You Pay Without Medicare: $40 copay
Standard Option You Pay With Medicare Part B: $0
Wellness Option You Pay Without Medicare: $30 copay
Wellness Option You Pay With Medicare Part B: $0

Benefit Description: Inpatient Hospital
High Option You Pay Without Medicare: $100 copay/day, $500 copay maximum
High Option You Pay With Medicare Part B: $0
Standard Option You Pay Without Medicare: 30% Coinsurance, Subject to Deductible, $2,000 max per admission
Standard Option You Pay With Medicare Part B: $0
Wellness Option You Pay Without Medicare:  30% coinsurance
Wellness Option You Pay With Medicare Parts B: $0

Benefit Description: Outpatient Hospital
High Option You Pay Without Medicare: $200 copay
High Option You Pay With Medicare Part B: $0
Standard Option You Pay Without Medicare: 30% Coinsurance, Subject to Deductible, $2,000 max per admission
Standard Option You Pay With Medicare Part B: $0
Wellness Option You Pay Without Medicare:  30% coinsurance
Wellness Option You Pay With Medicare Part B: $0

Benefit Description: Incentives Offered
High Option You Pay Without Medicare: N/A
High Option You Pay With Medicare Part B: N/A
Standard Option You Pay Without Medicare: N/A
Standard Option You Pay With Medicare Part B: N/A
Wellness Option You Pay Without Medicare: N/A
Wellness Option You Pay With Medicare Part B: N/A

• Tell us about your Medicare coverage

• Medicare Advantage (Part C)

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 health care choices (like HMOs and regional PPOs) in some areas of the country. To learn more about Medicare Advantage plans, contact Medicare at 800-MEDICARE (1-800-633-4227) or at www.medicare.gov.

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

This Plan and our Medicare Advantage plan:

You may enroll in the Presbyterian Senior Care Medicare Advantage Plan for FEHBP and also remain enrolled in the Presbyterian Health Plan’s FEHBP Commercial Plan. The Presbyterian Senior Care Medicare Advantage Plan will be primary and the Presbyterian Health Plan’s FEHBP Commercial plan will have coverage for prescription drugs. So, if you are enrolled in Medicare Part D, the Presbyterian Health Plan FEHBP Commercial plan will coordinate your prescription drug coverage with Medicare Part D. You must select a primary care provider from the Presbyterian Senior Care Plan, however, referrals are not required for network specialists, except for: Podiatry; Otolaryngology (Ear, Nose, and Throat); Occupational, Physical and Speech/Language Therapies. Presbyterian Senior Care and Presbyterian Health Plan’s FEHBP Commercial plan will coordinate your medical benefits.

This Plan and another plan’s Medicare Advantage plan: You may enroll in another plan’s Medicare Advantage plan and also remain enrolled in our FEHB plan. We will still provide benefits when your Medicare Advantage plan is primary, even out of the Medicare Advantage plan’s network and/or service area (if you use our Plan providers). However,we will not waive any of our copays, coinsurance, or deductibles. If you enroll in a Medicare Advantage plan, tell us. We will need to know whether you are in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly coordinate benefits with Medicare.

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

• Medicare prescription drug coverage (Part D)

Clinical Trials Cost Categories

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 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.

Coinsurance

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

Copay

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

Cost-sharing

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

Deductible

See Section 4, page 21.

Plan allowance

Plan allowance means the maximum dollar amount that an insurer will consider reimbursing for a covered service or procedure. This dollar amount may not be the amount ultimately paid to the provider as it  may be reduced by the co-insurance, deductible or amount beyond the annual maximum.

Urgent care claims

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

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

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

Urgent care claims usually involve pre-service claims and not post-service claims. We will determine whether or not the 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 Center at 505-923-5678 or 800-356-2219 or TTY for the hearing impaired at 711 or toll-free at 800-659-8331 or by accessing our website at www.phs.org/fehb.  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.

Deductible

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 page (Applies to printed brochure only).

Medical services provided by physicians: Diagnostic and treatment services provided in the office

Office visit copay:
Primary Care Physician $25 - $0 copay per visit for children up to age 26
Specialist $40 - $20 copay per visit for children up to age 26

(Waived if nursing visit only for allergy injections, injections such as insulin, heparin, and antibiotics, preventive adult and child immunizations)

25

Services provided by a hospital: Inpatient

$100/day up to 5 days

53

Services provided by a hospital: Outpatient

$150

54

Emergency benefits: In-area

$40 urgent care center; $150 for ER visit

58

Emergency benefits: Out-of-area

$40 urgent care center; $150 for ER visit

59

Mental health and substance use disorder treatment:

Regular cost sharing

$25 copay per visit

$0 copay per office visit for children up to age 26

61-62

Prescription drugs (Retail and Mail Order)

Tier 0 - $0 Maintenance Medication (for certain chronic conditions); Mail order $0

Tier 1 - $10 Generic (Preferred) drugs; Mail order $20

Tier 2 - $50 Brand (Preferred) drugs; Mail order $100

Tier 3 - $75 non-Brand (Non-preferred) drugs; Mail order $150

Tier 4 – Specialty Pharmaceuticals

50% of the plan allowance up to a maximum out-of-pocket of $400 per prescription; Not available mail order

66-74

Dental care

Limited benefit.
Applicable physician visit copay

75-76

Vision care

30% of the plan allowance
Applicable physician visit copay (eye exam for children).

35

Special features: 

Flexible benefits option; Services for deaf and hearing impaired, pregnancies, Presbyterian Healthcare Services, vision, acupuncture, chiropractic, cancer clinical trials, massage therapy, meals on wheels, fitness center, vision and hearing hardware discounts.

80

Protection against catastrophic costs

(your out-of-pocket maximum):

Nothing after $6,350/Self Only or $12,700/Self Plus One and Self and Family enrollment per year

Some costs do not count toward this protection

21

Medical services provided by physicians: Diagnostic and treatment services provided in the office

Office visit copay:
Primary Care Physician $30
Specialist $40

(Waived if nursing visit only for allergy injections, injections such as insulin, heparin, and antibiotics, preventive adult and child immunizations)

25

Services provided by a hospital: Outpatient

30% coinsurance * /$2,000 Max per surgery
Deductible applies

54

Services provided by a hospital: Inpatient

30% coinsurance * /$2,000 Max per admission
Deductible applies

53

Emergency benefits: Out-of-area

$40 urgent care center; $200 for ER visit

59

Emergency benefits: In-area

$40 urgent care center; $200 for ER visit

58

Mental health and substance use disorder treatment:

Regular cost sharing

$30 copay per visit

No deductible

61-62

Prescription drugs (Retail and Mail Order)

Tier 0 - $0 Maintenance Medication (for certain chronic conditions); $0 Mail order

Tier 1 - $10 Generic (Preferred) drugs; $20 Mail order

Tier 2 -  $50 Brand (Preferred) drugs; $100 Mail order

Tier 3 - $75 non-Brand (Non-preferred) drugs; $150 Mail order

Tier 4 - Specialty Pharmaceuticals

50% of the plan allowance up to a maximum out-of-pocket of $400 per prescription, not available mail order

66-74

Dental care

Limited benefit

Applicable physician visit copay

75-76

Vision care

50% of the plan allowance

Applicable physician visit copay (eye exam for children).

35

Special features:  

Flexible benefits option; Services for deaf and hearing impaired, pregnancies, Presbyterian Healthcare Services, vision, acupuncture, chiropractic, cancer clinical trials, massage therapy, meals on wheels, fitness center, vision and hearing hardware discounts.

80

Protection against catastrophic costs

(your out-of-pocket maximum):

Nothing after $6,350/Self Only or $12,700/Self Plus One enrollment or Self and Family enrollment per year.

Some costs do not count toward this protection.

21

Medical services provided by physicians: Diagnostic and treatment services provided in the office

Office visit copay

Primary Care Physician First 4 visits: $20 copay

Subsequent visits: 30% coinsurance*

Specialist $30 copay

25

Services provided by a hospital: Inpatient

30% coinsurance*

53

Services provided by a hospital: Outpatient

30% coinsurance*

54

Emergency benefits: In-area

Urgent care $30 per visit 

Emergency First 2 visits: $250 copay

Subsequent Visits: 30% coinsurance* 

58

Emergency benefits: Out of the area 

Urgent care $30 copay

Emergency First 2 visits $250 copay

Subsequent Visits: 30% coinsurance*

59

Mental Health and Substance use disorder treatment 

Regular cost sharing

First 4 visits $20 copay

Subsequent visits 30% coinsurance*

61-62

Prescription drugs (Retail and Mail Order)

Tier 0 - $0 Maintenance Medication (for certain Chronic conditions): Mail order $0

Tier 1 - $10 Generic (Preferred) drugs; Mail order $20

Tier 2 - $50 Brand (Preferred) drugs; Mail order $100

Tier 3 - $75 non-Brand (Non-preferred) drugs; Mail order $150

Tier 4 - Specialty Pharmaceuticals 

50% of the plan allowance up to maximum of $400 per prescription (Not subject to deductible) 

Not available mail order.

66-74

Dental Care

Limited benefit. 

Applicable physician visit ocpayment 

75-76

Vision

30% of the plan allowance 

Applicable physician visit copay (eye exam for children). 

35

Special features:  

Flexible benefits option: Services for deaf and hearing impaired, Presbyterian Healthcare Services, vision, acupuncture, chiropractic, cancer clinical trails, massage therapy, meals on wheels, fitness center, vision and hearing hardware discounts.

80

Protection against catastrophic costs 

(your out-of-pocket maximum):

Nothing after $8,150/Self Only or $16,300/Self Plus One and Self and Family enrollment per year

Some costs do not count toward this protection

21