Coventry Health Care
www.chcde.com
1-800-833-7423
2013
A Health Maintenance Organization (high and standard option) with a
high deductible health plan option
IMPORTANT
• Rates: Back Cover
• Changes for 2013: Page 13
• Summary of benefits: Page 125
Serving:
All of Maryland
Enrollment in this Plan is limited. You must live or work in the
State of Maryland. See page 12 for requirements
Maryland:
IG1 High Option – Self Only
IG2 High Option – Self and Family
IG4 Standard Option – Self Only
IG5 Standard Option – Self and Family
GZ1 HDHP Option – Self Only
GZ2 HDHP Option – Self and Family
RI 73-836
Important Notice from Coventry Health Care About
Our Prescription Drug Coverage and Medicare
OPM has determined that the Coventry Health Care prescription drug coverage is, on average, comparable to Medicare Part
D prescription drug coverage; thus you do not need to enroll in Medicare Part D and pay extra for prescription drug benefits.
If you decide to enroll in Medicare Part D later, you will not have to pay a penalty for late enrollment as long as you keep
your FEHB coverage.
However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and will coordinate benefits with
Medicare.
Remember: If you are an annuitant and you cancel your FEHB coverage, you may not re-enroll in the FEHB Program.
Please be advised
If you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that’s as least as good
as Medicare’s prescription drug coverage, your monthly premium will go up a least 1% per month for every month that you
did not have that coverage. For example, if you go 19 months without Medicare Part D prescription drug coverage, your
premium will always be at least 19 percent higher than what many other people pay. You’ll have to pay this higher premium
as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the Annual Coordinated
Election Period (October 15th through December 7th) to enroll in Medicare Part D.
Medicare’s Low Income Benefits
For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available.
Information regarding this program is available through the Social Security Administration (SSA) online at www.
socialsecurity.gov , or call the SSA at 1-800-772-1213 (TTY 1-800-325-0778).
You can get more information about Medicare prescription drug plans and the coverage offered in your area from these
places:
•Visit www.medicare.gov for personalized help.
•Call 1-800-MEDICARE (1-800-633-4227), (TTY 1-877-486-2048).
Table of Contents
Table of Contents ..........................................................................................................................................................................1
Introduction ...................................................................................................................................................................................3
Plain Language ..............................................................................................................................................................................3
Stop Health Care Fraud! ...............................................................................................................................................................3
Preventing Medical Mistakes ........................................................................................................................................................4
FEHB Facts ...................................................................................................................................................................................7
Coverage information .........................................................................................................................................................7
• No pre-existing condition limitation ...............................................................................................................................7
• Where you can get information about enrolling in the FEHB Program .........................................................................7
• Types of coverage available for you and your family ....................................................................................................7
• Family member coverage ...............................................................................................................................................8
• Children’s Equity Act .....................................................................................................................................................8
• When benefits and premiums start .................................................................................................................................9
• When you retire ..............................................................................................................................................................9
When you lose benefits .......................................................................................................................................................8
• When FEHB coverage ends ............................................................................................................................................9
• Upon divorce ..................................................................................................................................................................9
• Temporary Continuation of Coverage (TCC) ...............................................................................................................10
• Converting to individual coverage ...............................................................................................................................10
• Getting a Certificate of Group Health Plan Coverage ..................................................................................................10
Section 1. How this plan works ...................................................................................................................................................11
General features of our High and Standard Options .........................................................................................................11
How we pay providers ......................................................................................................................................................11
General features of our High Deductible Health Plan ......................................................................................................11
Your rights .........................................................................................................................................................................12
Your medical and claims records are confidential ............................................................................................................12
Service Area ......................................................................................................................................................................12
Section 2. Changes for 2013 .......................................................................................................................................................13
Changes to this Plan ..........................................................................................................................................................13
Section 3. How you get care .......................................................................................................................................................14
Identification cards ............................................................................................................................................................14
Where you get covered care ..............................................................................................................................................14
• Network providers and facilities ...................................................................................................................................14
• Out-of-network providers and facilities .......................................................................................................................15
What you must do to get covered care ..............................................................................................................................15
• Primary care ..................................................................................................................................................................15
• Specialty care ................................................................................................................................................................15
• Hospital care .................................................................................................................................................................16
If you are hospitalized when your enrollment begins .......................................................................................................16
Other services ....................................................................................................................................................................17
• You need prior Plan approval for certain services ..............................................................................................17
If you are hospitalized when your enrollment begins .............................................................................................16
Inpatient hospital admission ...................................................................................................................................17
How to request precertification of an admission or get prior authorization for Other services ..............................19
Non-urgent care claims ...........................................................................................................................................19
Urgent care claims ..................................................................................................................................................19
1 2013 Coventry Health Care Table of Contents
Emergency inpatient admission ..............................................................................................................................20
If your treatment needs to be extended ...................................................................................................................20
What happens when you do not follow the precertification rules when using non-network facilities ...................20
If you disagree with our pre-service claim decision ...............................................................................................20
To reconsider a non-urgent care claim ....................................................................................................................20
To reconsider an urgent care claim .........................................................................................................................20
To file an appeal with OPM ....................................................................................................................................21
Section 4. Your costs for covered services ..................................................................................................................................22
Copayments .......................................................................................................................................................................22
Deductible .........................................................................................................................................................................22
Coinsurance .......................................................................................................................................................................22
Differences between our Plan allowance and the bill .......................................................................................................23
Your catastrophic protection out-of-pocket maximum .....................................................................................................23
Carryover ..........................................................................................................................................................................23
Section 5. Benefits ......................................................................................................................................................................24
High and Standard Option Benefits ..................................................................................................................................24
High Deductible Health Plan Benefits ..............................................................................................................................60
Section 6. General exclusions – services, drugs, and supplies we do not cover. ......................................................................105
Section 7. Filing a claim for covered services ..........................................................................................................................106
Section 8. The disputed claims process .....................................................................................................................................108
Section 9. Coordinating benefits with Medicare and other coverage ........................................................................................111
When you have other health coverage ............................................................................................................................111
TRICARE and CHAMPVA .............................................................................................................................................111
Workers’ Compensation ..................................................................................................................................................111
Medicaid ..........................................................................................................................................................................111
When other Government agencies are responsible for your care ....................................................................................111
When others are responsible for injuries .........................................................................................................................112
When you have MedicareWhat is Medicare? .................................................................................................................112
• Should I enroll in Medicare? ......................................................................................................................................113
• The Original Medicare Plan (Part A or Part B) ...........................................................................................................113
• Medicare Advantage (Part C) .....................................................................................................................................114
• Medicare prescription drug coverage (Part D) ...........................................................................................................113
Section 10. Definitions of terms we use in this brochure ..........................................................................................................117
Section 11. Other Federal Programs .........................................................................................................................................121
The Federal Flexible Spending Account Program - FSAFEDS ......................................................................................121
The Federal Employees Dental and Vision Insurance Program - FEDVIP ....................................................................122
The Federal Long Term Care Insurance Program - FLTCIP ..........................................................................................123
Pre-existing Condition Insurance Program (PCIP) .........................................................................................................123
Index ..........................................................................................................................................................................................124
Summary of benefits for the High Option of Coventry Health Care - 2013 .............................................................................125
Summary of benefits for the Standard Option of Coventry Health Care - 2013 ......................................................................127
Summary of benefits for the HDHP of Coventry Health Care - 2013 ......................................................................................129
2013 Rate Information for Coventry Health Care-Maryland ....................................................................................................131
2 2013 Coventry Health Care Table of Contents
Introduction
This brochure describes the benefits of Coventry Health Care under our contract (CS 2892) with the United States Office of
Personnel Management, as authorized by the Federal Employees Health Benefits law. Customer Service may be reached at
800-833-7423 or through our wesbite: www.cvty.com The address for Coventry's administrative offices is:
Coventry Health Care
750 Prides Crossing, Suite 300
Newark, DE 19713
This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations,
and exclusions of this brochure. It is your responsibility to be informed about your health benefits.
If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self and
Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were
available before January 1, 2013, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2013, and changes are
summarized on page 9. Rates are shown at the end of this brochure.
Plain Language
All FEHB brochures are written in plain language to make them easy to understand. Here are some examples:
•Except for necessary technical terms, we use common words. For instance, “you” means the enrollee or family member,
“we” means Coventry Health Care
.
•We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United States
Office of Personnel Management. If we use others, we tell you what they mean first.
•Our brochure and other FEHB plans’ brochures have the same format and similar descriptions to help you compare plans.
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits Program
premium.
OPM’s Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program
regardless of the agency that employs you or from which you retired.
Protect Yourself From Fraud – Here are some things that you can do to prevent fraud:
•Do not give your plan identification (ID) number over the telephone or to people you do not know, except for your health
care providers, authorized health benefits plan, or OPM representative.
•Let only the appropriate medical professionals review your medical record or recommend services.
•Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to
get it paid.
•Carefully review explanations of benefits (EOBs) that you receive from us.
•Periodically review your claim history for accuracy to ensure we have not been billed for services that you did not receive.
•Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.
•If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or
misrepresented any information, do the following:
- Call the provider and ask for an explanation. There may be an error.
3 2013 Coventry Health Care Introduction/Plain Language/Advisory
- If the provider does not resolve the matter, call us at 800-833-7423 and explain the situation.
- If we do not resolve the issue:
CALL - THE HEALTH CARE FRAUD HOTLINE
877-499-7295
OR go to www.opm.gove/oig
You can also write to:
United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington, DC20415-1100
•Do not maintain as a family member on your policy:
- Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise)
- Your child age 26 (unless he/she is disabled and incapable of self-support prior to age 26)
•If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed, with
your retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under
Temporary Continuation of Coverage.
•Fraud or intentional misrepresentation of material fact is prohibited under the Plan. You can be prosecuted for fraud and
your agency may take action against you. Examples of fraud include, falsifying a claim to obtain FEHB benefits, trying to
or obtaining service or coverage for yourself or for someone else who is not eligible for coverage, or enrolling in the Plan
when you are no longer eligible.
•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. 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 is no
longer eligible to use your health insurance coverage.
Preventing Medical Mistakes
An influential report from the Institute of Medicine estimates that up to 98,000 Americans die every year from medical
mistakes in hospitals alone. That’s about 3,230 preventable deaths in the FEHB Program a year. While death is the most
tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer
recoveries, and even additional treatments. By asking questions, learning more and understanding your risks, you can
improve the safety of your own health care, and that of your family members. Take these simple steps:
1. Ask questions if you have doubts or concerns.
•Ask questions and make sure you understand the answers.
•Choose a doctor with whom you feel comfortable talking.
•Take a relative or friend with you to help you ask questions and understand answers.
2. Keep and bring a list of all the medicines you take.
•Bring the actual medicines or give your doctor and pharmacist a list of all the medicines and dosages that you take,
including non-prescription (over-the-counter) medicines and nutritional supplements.
•Tell your doctor and pharmacist about any drug allergies you have.
4 2013 Coventry Health Care Introduction/Plain Language/Advisory
•Ask about any risks or side effects of the medication and what to avoid while taking it. Be sure to write down what your
doctor or pharmacist says.
•Make sure your medicine is what the doctor ordered. Ask the pharmacist about your medicine if it looks different than you
expected.
•Read the label and patient package insert when you get your medicine, including all warnings and instructions.
•Know how to use your medicine. Especially note the times and conditions when your medicine should and should not be
taken.
•Contact your doctor or pharmacist if you have any questions.
3. Get the results of any test or procedure.
•Ask when and how you will get the results of tests or procedures.
•Don’t assume the results are fine if you do not get them when expected, be it in person, by phone, or by mail.
•Call your doctor and ask for your results.
•Ask what the results mean for your care.
4. Talk to your doctor about which hospital is best for your health needs.
•Ask your doctor about which hospital has the best care and results for your condition if you have more than one hospital to
choose from to get the health care you need.
•Be sure you understand the instructions you get about follow-up care when you leave the hospital.
5. Make sure you understand what will happen if you need surgery.
•Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.
•Ask your doctor, “Who will manage my care when I am in the hospital?”
•Ask your surgeon:
- "Exactly what will you be doing?"
- "About how long will it take?"
- "What will happen after surgery?"
- "How can I expect to feel during recovery?"
•Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reaction to anesthesia, and any medications you are
taking.
Patient Safety Links
- www.ahrq.gov/consumer/. The Agency for Healthcare Research and Quality makes available a wide-ranging list of topics
not only to inform consumers about patient safety but to help choose quality health care providers and improve the quality of
care you receive.
- www.npsf.org. The National Patient Safety Foundation has information on how to ensure safer health care for you and your
family.
- www.talkaboutrx.org. The National Council on Patient Information and Education is dedicated to improving
communication about the safe, appropriate use of medicines.
- www.leapfroggroup.org. The Leapfrog Group is active in promoting safe practices in hospital care.
- www.ahqa.org. The American Health Quality Association represents organizations and health care professionals working to
improve patient safety.
5 2013 Coventry Health Care Introduction/Plain Language/Advisory
Never Events
You will not be billed for inpatient services related to treatment of specific hospital acquired conditions or for inpatient
services needed to correct Never Events if you use Coventry participating providers. This policy helps to protect you from
preventable medical errors and improve the quality of care you receive.
When you enter the hospital for treatment on one medical problem, you don't expect to leave with additional injuries,
infections or other serious conditions that occur during the course of your stay. Although some of these complications may
not be avoidable, too often patient suffer from injuries or illnesses that could have been prevented if the hospital had taken
proper precautions.
We have a benefit payment policy that encourages hospitals to reduce the likelihood of hospital-acquired conditions such as
certain infections, severe bedsores and fractures; and reduce medical errors that should never happen called "Never Events".
When a Never Event occurs neither FEHB nor you will incur costs to correct the medical error.
6 2013 Coventry Health Care Introduction/Plain Language/Advisory
FEHB Facts
Coverage information
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.
• No pre-existing
condition limitation
See www.opm.gov/insure/health 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 who 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 a
Guide to Federal Benefits,
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
• what happens when your enrollment ends
• 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 or
retirement office.
• Where you can get
information about
enrolling in the FEHB
Program
Self Only coverage is for you alone. Self and Family coverage is for you, your spouse,
and your dependent children, including any foster children your employing or retirement
office authorizes coverage for. 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 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 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 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 marry.
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 26.
If you or one of your family members is enrolled in one FEHB plan, that person may
not be enrolled in or covered as a family member by another FEHB plan.
If you have a qualifying life event (QLE) - such as marriage, divorce, or the birth of a
child - outside of the Federal Benefits Open Season, you may be eligible to enroll in the
FEHB Program, change your enrollment, or cancel coverage. For a complete list of
QLEs, visit the FEHB website at www.opm.gov/insure/lifeevents. If you need assistance,
please contact your employing agency, personnell/payroll office, or retirement office.
• Types of coverage
available for you and
your family
7 2013 Coventry Health Care
.
Family members covered under your Self and Family enrollment are your spouse
(including a valid common law marriage) and children as described in the chart below.
ChildrenCoverage
Natural, adopted children, and stepchildren Natural, adopted children and stepchildren
are covered until their 26
th
birthday.
Foster Children Foster children are eligible for coverage
until their 26
th
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 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 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
Children who are eligible for or have their
own employer-provided health insurance are
covered until their 26th birthday.
You can find additional information at www.opm.gov/insure .
• Family member
coverage
OPM has implemented the Federal Employees Health Benefits Children’s Equity Act of
2000. This law mandates that you be enrolled for 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 for 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 and
Family coverage in the Blue Cross and Blue Shield Service Benefit Plan’s Basic
Option
• 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 and Family in the same option of the same plan
• 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 and Family in the Blue
Cross and Blue Shield Service Benefit Plan’s Basic Option
• Children’s Equity Act
8 2013 Coventry Health Care
As long as the court/administrative order is in effect, and you have at least one child
identified in the order who is still eligible under the FEHB Program, you cannot cancel
your enrollment, change to Self Only, or change to a plan that doesn’t serve the area in
which your children live, unless you provide documentation that you have other coverage
for the children. If the court/administrative order is still in effect when you retire, and you
have at least one child still eligible for FEHB coverage, you must continue your FEHB
coverage into retirement (if eligible) and cannot cancel your coverage, change to Self
Only, or change to a plan that doesn’t serve the area in which your children live as long as
the court/administrative order is in effect. Contact your employing office for further
information.
The benefits in this brochure are effective January 1. If you joined this Plan during Open
Season, your coverage begins on the first day of your first pay period that starts on or after
January 1. If you changed plans or plan options during Open Season and you receive
care between January 1 and the effective date of coverage under your new plan or
option, your claims will be paid according to the 2013 benefits of your old plan or
option. However, if your old plan left the FEHB Program at the end of the year, you are
covered under that plan’s 2012 benefits until the effective date of your coverage with your
new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any
other time during the year, your employing office will tell you the effective date of
coverage.
If your enrollment continues after you are no longer eligible for coverage (i.e. you have
separated from Federal service) and premiums are not paid, you will be responsible for all
benefits paid during the period in which premiums were not paid. You may be billed for
services received directly from your provider. You may be prosecuted for fraud for
knowingly using health insurance benefits for which you have not paid premiums. It is
your responsibility to know when you or a family member are no longer eligible to use
your health insurance coverage.
• When benefits and
premiums start
When you retire, you can usually stay in the FEHB Program. Generally, you must have
been enrolled in the FEHB 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).
• When you retire
When you lose benefits
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 extensio 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.
You may be eligible for spouse equity coverage or Temporary Continuation of Coverage
(TCC), or a conversion policy (a non-FEHB individual policy.)
• When FEHB coverage
ends
If you are divorced from a Federal employee or 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 for you. However, you may be
eligible for your own FEHB coverage under either the spouse equity law or Temporary
Continuation of Coverage (TCC). If you are recently divorced or are anticipating a
divorce, contact your ex-spouse’s employing or retirement office to get RI 70-5, the
Guide
to Federal Benefits for Temporary Continuation of Coverage and Former Spouse
Enrollees,
or other information about your coverage choices. You can also download the
guide from OPM’s Web site, www.opm.gov/insure.
• Upon divorce
9 2013 Coventry Health Care
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 FEHB enrollment after
you retire, if you lose your Federal job, if you are a covered dependent 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, and the RI 70-5, the
Guide to
Federal Benefits for Temporary Continuation of Coverage and Former Spouse Enrollees,
from your employing or retirement office or from www.opm.gov/insure. It explains what
you have to do to enroll.
• Temporary
Continuation of
Coverage (TCC)
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 service, your employing office will notify you of your right to
convert. You must apply in writing to us 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 apply in writing to us 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, and we will not impose a waiting period
or limit your coverage due to pre-existing conditions.
• Converting to
individual coverage
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a Federal
law that offers limited Federal protections for health coverage availability and continuity
to people who lose employer group coverage. If you leave the FEHB Program, we will
give you a Certificate of Group Health Plan Coverage that indicates how long you have
been enrolled with us. You can use this certificate when getting health insurance or other
health care coverage. Your new plan must reduce or eliminate waiting periods, limitations,
or exclusions for health related conditions based on the information in the certificate, as
long as you enroll within 63 days of losing coverage under this Plan. If you have been
enrolled with us for less than 12 months, but were previously enrolled in other FEHB
plans, you may also request a certificate from those plans.
For more information, get OPM pamphlet RI 79-27,
Temporary Continuation of Coverage
(TCC) under the FEHB Program
. See also the FEHB Web site at www.opm.gov/insure/
health; refer to the “TCC and HIPAA” frequently asked questions. These highlight
HIPAA rules, such as the requirement that Federal employees must exhaust any TCC
eligibility as one condition for guaranteed access to individual health coverage under
HIPAA, and information about Federal and State agencies you can contact for more
information.
• Getting a Certificate
of Group Health Plan
Coverage
10 2013 Coventry Health Care
Section 1. How this plan works
General features of our High and Standard Options
The High and Standard Options are individual practice Open Access health maintenance organization (HMO) plans. This
means you can receive covered services from a participating provider without a required referral from your primary care
physician or by another participating provider in the network. We require you to see specific physicians, hospitals, and other
providers that contract with us. These Plan providers coordinate your health care services. The Plan is solely responsible for
the selection of these providers in your area. Contact the Plan for a copy of their most recent provider directory.
HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in
addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any
course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You pay only the
copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan
providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan’s benefits, not because a particular provider is available. You
cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or
other provider will be available and/or remain under contract with us.
How we pay providers
Payment for Covered Services will be made by Us directly to the Participating Provider. For Medical Emergency and Urgent
Care services, payment will be made by us directly to the Provider or may, at our discretion, be made to you. Participating
Providers may not, under any circumstances, seek payment from you except for Copayments, Coinsurance, and payments for
Non-authorized or non-Covered Services.
General features of our High Deductible Health Plan (HDHP)
HDHPs have higher annual deductibles and annual out-of-pocket maximum limits than other types of FEHB plans. FEHB
Program HDHP's also offer health savings accounts or health reimbursement arrangements. Please see below of more
information about these savings features.
Preventive care services
Preventive care services are generally covered with no cost-sharing and are not subject to copayments, deductibles, or
annual limits when received from a network provider.
Annual deductible
The annual deductible must be met before Plan benefits are paid for care other than preventive care services.
Health Savings Account (HSA)
You are eligible for an HSA if you are enrolled in an HDHP, not covered by any other health plan that is not an HDHP
(including a spouse’s health plan, but does not include specific injury insurance and accident, disability, dental care, vision
care, or long-term coverage), not enrolled in Medicare, not received VA benefits within the last three months, not covered by
your own or our spouse's flexible spending account (FSA), and are not claimed as a dependent on someone else’s tax return.
•You may use the money in your HSA to pay all or a portion of the annual deductible, copayments, coinsurance, or other
out-of-pocket costs that meet the IRS definition of a qualified medical expense.
•Distributions from your HSA are tax-free for qualified medical expenses for you, your spouse, and your dependents, even
if they are not covered by a HDHP.
•You may withdraw money from your HSA for items other than qualified medical expenses, but it will be subject to income
tax and, if you are under 65 years old, an additional 20% penalty tax on the amount withdrawn.
11 2013 Coventry Health Care Section 1
•For each month that you are enrolled in an HDHP and eligible for an HSA, the HDHP will pass through (contribute) a
portion of the health plan premium to your HSA. In addition, you (the account holder) may contribute your own money to
your HSA up to an allowable amount determined by IRS rules. Your HSA dollars earn tax-free interest.
•You may allow the contributions in your HSA to grow over time, like a savings account. The HSA is portable – you may
take the HSA with you if you leave the Federal government or switch to another plan.
Health Reimbursement Arrangement (HRA)
If you are not eligible for an HSA, or become ineligible to continue an HSA, you are eligible for a Health Reimbursement
Arrangement (HRA). Although an HRA is similar to an HSA, there are major differences.
•An HRA does not earn interest.
•An HRA is not portable if you leave the Federal government or switch to another plan.
Catastrophic protection
We protect you against catastrophic out-of-pocket expenses for covered services. Your annual out-of-pocket expenses for
covered services, including deductibles and copayments, cannot exceed $6,250 for Self Only enrollment, or $12,500 family
coverage.
Your rights
OPM requires that all FEHB plans provide certain information to their FEHB members. You may get information about us,
our networks, and our providers. OPM’s FEHB Web site (www.opm.gov/insure) lists the specific types of information that
we must make available to you. Some of the required information is listed below.
•Years in existence
•Profit status
If you want more information about us, call 302-283-6500 in Delaware or 800-833-7423 outside of Delaware or write to
Coventry Health Care at 750 Prides Crossing, Suite 300, Newark, DE 19713. You may also contact us by fax at
866-858-1522 or visit our Web site at www.chcde.com.
Your medical and claims records are confidential:
We will keep your medical and claims records confidential. Please note that as part of our administration of this contract, we
may disclose your medical and claims information (including your prescription drug utilization) to any treating physicians or
dispensing pharmacies.
Service Area
To enroll in this Plan, you must live or work in the State of Maryland. You can receive services in our service area. This is
where our providers practice. Our service area is all of Maryland, Delaware and certain counties in Pennsylvania and New
Jersey. You can contact Customer Service at 800-833-7423 to confirm network availability.
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will
pay only for emergency care benefits. We will not pay for any other health care services out of our service area unless the
services have prior plan approval.
If you or a covered family member move outside of the service area, you can enroll in another plan. If your dependents live
out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service
plan or another plan that has agreements with affiliates in other areas. If you or a family member moves, you do not have to
wait until Open Season to change plans. Contact your employing or retirement office.
12 2013 Coventry Health Care Section 1
Section 2. Changes for 2013
Do not rely only on these change descriptions; this Section is not an official statement of benefits. For that, go to Section 5,
Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.
PROGRAM WIDE CHANGES for 2013
•Annual limits on essential health benefits as described in section 1302 of the Affordable Care Act have been eliminated.
•FEHB Plans must provide coverage for routine patient costs for items and services furnished in connection with
participation in an approved clinical trial.
•Additional coverage for preventive care and screenings for women provided in comprehensive guidelines adopted by the
Health Resources and Services Administration (HRSA) has been added with no cost-sharing in network.
Changes to High Option only
•Your share of the non-Postal premium will increase for Self Only and for Self and Family. See page 127.
•No benefit changes.
Changes to Standard Option only
•Your share of the non-Postal premium will increase for Self Only and for Self and Family. See page 127.
•No benefit changes.
Changes to High Deductible Health Plan
•Your share of the non-Postal premium will increase for Self Only and for Self and Family. See page 127.
•No benefit changes.
13 2013 Coventry Health Care Section 2
Section 3. How you get care
We will send you an identification (ID) card when you enroll. You should carry your ID
card with you at all times. You must show it whenever you receive services from a Plan
provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use
your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment
confirmation letter (for annuitants), or your electronic enrollment system (such as
Employee Express) confirmation letter.
If you do not receive your ID card within 30 days after the effective date of your
enrollment, or if you need replacement cards, call us at 800-833-7423 or write to us
COVENTRY HEALTH CARE
750 Prides Crossing
Suite 300
Newark, DE 19713
You may also request replacement cards through our Web site at www.chcde.com through
My Online Services.
Identification cards
You get care from “Plan providers” and “Plan facilities.” You will only pay copayments,
deductibles, and/or coinsurance, and you can receive covered services from a participating
provider without a required referral from your primary care physician or by another
participating provider in the network. If you go to a non-Participating Provider, benefits
will be denied, except for Emergency Services and Urgent Care Services outside the
Service Area and certain referrals as provided for below.
Where you get covered
care
Plan providers are physicians and other health care professionals in our service area that
we contract with to provide covered services to our members. Members are responsible
for verifying provider participation.
A member may get information about our participating provider network by checking the
Provider Directory; calling our Customer Service Department at 302-283-6500 within our
service area or 800-833-7423; or logging on to our website at www.chcde.com. We
reserve the right to make changes in our participating provider network as is appropriate
or necessary.
We credential plan providers according to national standards. Coventry has been awarded
full accreditation under the Health Plan standards of URAC (American Accreditation
HealthCare Commission), including provider credentialing.
When services are rendered by a Plan Provider, payment will be made to the Provider for
services rendered. Members are responsible for any copayment, deductible, or
coinsurance and payment of an unauthorized or non-covered Service.
When a Covered Service is rendered to a Member by a Non-Plan Provider, We shall pay
the Out-of-Network Plan Allowance for Covered Services within 30 days after the receipt
of a claim. We shall determine, in Our sole discretion, whether to accept assignment of
payment of the claim. Therefore, We reserve the right to pay either You or the Non-Plan
Provider. In addition, if a Member is covered as a Dependent child under a Qualified
Medical Child Support Order or other court or administrative order applicable to the
Group, who is not the Subscriber/Member, receives covered expenses on the Dependent
child’s behalf, We reserve the right to make payment for these covered expenses to the
non-Subscriber/Member parent or the Provider. Payment will, in either case, be full and
complete satisfaction of benefit and payment obligations under this Plan.
• Network providers
and facilities
14 2013 Coventry Health Care Section 3
Plan facilities are hospitals and other facilities in our service area that we contract with to
provide covered services to our members. Members are responsible for verifying provider
participation. A member may get information about our participating provider network by
checking the Provider Directory; calling our Customer Service Department at
302-283-6500 within our service area or 800-833-7423; or logging on to our website at
http://www.CHCDE.com/. As noted above, we reserve the right to make changes in our
participating network as is appropriate or necessary.
Your benefit plan does not have coverage for out of network facilities or providers without
prior authorization from Us, or if in the case on an Emergency situation and Urgent Care
Services outside the Service Area.
• Out-of-network
providers and
facilities
Carry your Identification Card at all times; this is your proof of coverage. Always seek
care from Participating Providers. The fact that a participating physician may prescribe,
order, recommend, or approve a service or supply does not by itself make the charge a
covered service. We will not cover a service or supply that is not medically necessary or
that is not a covered service, even if it is not specifically listed or described under an
exclusion or limitation, unless approved by Us.
To obtain benefits provided by this agreement, the member is subject to all terms,
conditions, limitations, and exclusions in this agreement. The member is also subject to
all of our rules and regulations. We retain the right to make all final decisions concerning
covered services.
What you must do to get
covered care
Our plan does not require you to pick a primary care physician, however you will need to
use a physician in the Coventry Health Care network. Your Primary Care Physician will
create your treatment plan. For certain services, your physician may have to get
authorization or approval from us beforehand. Before giving approval, we consider if the
service is covered, medically necessary, and follows generally accepted medical practice.
See the sections below for more information.
• Primary care
Our plan does not require you to obtain referrals to see specialists, however the provider
must be in our network. If you go to a non-participating provider, benefits will be denied,
except for Emergency Services and Urgent Care Services outside the Service Area and
certain referrals as provided for below.
Members may be covered for services rendered by a Non-Plan Provider if:
• the Member is diagnosed with a condition or disease that requires specialist medical
care and we do not have a Plan Provider with the professional training and expertise to
treat the condition or disease, and
• the Non-Plan Provider agrees to accept the same reimbursement as would be provided
to a Provider who is part of our provider panel.
For certain services, your physician may have to get authorization or approval from us
beforehand. Before giving approval, we consider if the service is covered, medically
necessary, and follows generally accepted medical practice. See the sections below for
more information.
• Specialty care
Here are some other things you should know about specialty care:
• If you need to see a specialist frequently because of a chronic, complex, or serious
medical condition, your primary care physician will develop a treatment plan that
allows you to see your specialist for a certain number of visits without additional
referrals. Your primary care physician will use our criteria when creating your
treatment plan (the physician may have to get an authorization or approval
beforehand).
15 2013 Coventry Health Care Section 3
• If you are seeing a specialist when you enroll in our Plan, talk to your primary care
physician. Your primary care physician will decide what treatment you need. If he or
she decides 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
physician, who will arrange for you to see 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
- 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 hospitalization is required, a Participating Physician will arrange admission to one of
our Participating Hospitals. A Participating Physician will care for you, or you will be
referred to a Participating Provider who will manage your care. All non-emergency
Hospital admissions must be Authorized by a Participating Physician and Coventry
Health Care prior to admission.
• Hospital care
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 800-833-7423. If you are new to the FEHB Program we will
arrange for you to receive care and provide benefits for your covered services while you
are in the hospital beginning on the effective date of your coverage.
If you changed from another FEHB plan to us, your former plan will pay for the hospital
stay until:
• you are discharged, not merely moved to an alternative care center;
• the day your benefits from your former plan run out; or
• the 92
nd
day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person. If your plan
terminates participation in the FEHB Program in whole or in part, or if OPM orders an
enrollment change, this continuation of coverage provision does not apply. In such case,
the hospitalized family member’s benefits under the new plan begin on the effective date
of enrollment.
• If you are hospitalized
when your enrollment
begins
16 2013 Coventry Health Care Section 3
Since we do not have a primary care physician requirement, you may need to obtain our
approval before you receive certain services. The pre-service claim approval processes
for inpatient hospitalization (called precertification) and for other services are detailed in
this Section. A pre-service claim is any claim, in whole or in part, that requires approval
from us in advance of obtaining medical care or services. In other words, a pre-service
claim for benefits (1) requires precertification or prior approval and (2) will result in a
denial if you do not obtain precertification or prior approval.
You need prior Plan
approval for certain
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.
• Inpatient hospital
admission
Since we do not have a primary care physician requirement and we allow you to use non-
Plan providers, you need to obtain our approval before you receive certain services. The
pre-service claim approval porcesses for inpatient hospital admissions (called
precertification) and for other services, are detailed in this Section. A pre-service claim is
any claim, in whole or in part, that requires approval from us in advance of obtaining
medical care services. in other words, a pre-service claim for benefits (1) requires
precertification, prior approval or a referral and (2) will result in denial or reduction of
benefits if you do not obtain precertification, prior approval or a referral.
Your physician must obtain approval for the following list of services:
• Ambulance Transport (except for emergency situations)
• Certain Prescription Drugs
• Chemotherapy
• Computed Tomography Scans (CT Scans)
• Durable Medical Equipment purchase price greater than $200 – all rentals require
authorization (personal, comfort and convenience items are a benefit exclusion)
• Eye Glasses or Corrective Lenses Required after Cataract Surgery
• Genetic Counseling
• Habilitative Services for Children under age 19
• Hair Prosthesis
• Hearing Aids
• Home Health Care
• Home Infusion Therapy
• Hospice
• Infertility Services
• Injectables other than those covered under CHCDE’s Formulary
• Inpatient Admission (i.e., Hospitals, Rehabilitation, Surgery, Skilled Nursing Facilities
and Sub-Acute Facilities)
• In Vitro Fertilization
• Magnetic Resonance Angiography (MRA)
• Magnetic Resonance Imaging (MRI)
• Maternity Care
• Mental Health and Substance Abuse Services
• Morbid Obesity Treatment
• Non-Participating Providers (except for Emergency Services)
• Nutritional Counseling performed by Providers other than Participating Physicians
• Outpatient procedures and surgical services performed in a hospital
• Other services
17 2013 Coventry Health Care Section 3
• Plastic/Cosmetic Surgery and Procedures
• Positron Emission Tomography (PET Scans)
• Therapies (i.e., Speech Therapy, Physical Therapy, Occupational Therapy, Cardiac
Rehabilitation/Therapy and Pulmonary Rehabilitation)
• Transplant and Transplant Evaluation
Authorization Process
The Participating Provider calls us for an Authorization within 10 days of the scheduled
admission or service. The Health Plan will:
• inform the Member’s Provider within 3 calendar days of the Authorization request
when we do not have enough information to make a decision;
• make a decision for a scheduled admission or service within 2 working days of
receiving the necessary information;
• make a decision for an extended stay in a health care facility within one working day
after receiving the necessary information;
• make a decision to provide additional services or extend the time for such services
within one working day after receiving the necessary information; and
• promptly notify the Member and the Member’s Provider of the decision.
If we do not authorize the care, we will notify the Member and the Member’s Provider of
the decision within 5 days after the decision has been made. If the Member’s Provider
disagrees with the decision, he or she may ask us to reconsider. We will give the Provider
the opportunity to speak with the physician who made the decision, by telephone, within
24 hours of when the Provider asked for reconsideration.
We will waive the prior authorization requirements for emergency admissions and urgent
care. However, the Member, a family member or the Provider needs to call us within 48
hours or as soon as possible to advise us of an emergency hospital admission.
Mental Health Admissions
Emergency mental health admissions do not require Authorization. We will not deny a
mental health admission during the first 24 hours of the inpatient admission when
• The Member is admitted because he or she is a danger to self or others;
• The Member’s Physician or psychologist consults with a medical staff member of the
facility who has admitting privileges and they determine the admission is necessary;
and
• The hospital notifies us immediately that the Member has been admitted and the
reason for the admission.
Emergency Admissions
For emergency inpatient admissions, we will not render an adverse decision solely
because the hospital did not notify us of the emergency admission within 48 hours after
that admission if the patient's medical condition prevented the hospital from determining:
• the patient's insurance status; and
• our emergency admission notification requirements.
Retroactive Adverse Decisionsfor Authorized Care
• Except as provided in the bullets below, if a course of treatment has been authorized
for a Member, we will not make an adverse decision for the authorized services.
• We may retrospectively render an adverse decision for authorized services if:
18 2013 Coventry Health Care Section 3
• the information submitted to us regarding the Member’s services was fraudulent or
intentionally misrepresentative;
• critical information requested by us regarding the Member’s services was omitted and
our determination would have been different had we known the critical information; or
• the Provider did not substantially follow the approved treatment plan for the Member.
First, your physician, your hospital, you, or your representative, must call us at
302-995-6100 or 800-727-9951 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 planned days of confinement.
How to request
precertification of an
admission or get prior
authorization for Other
services
For non-urgent care claims, we will then 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.
• Non-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 by applying
the judgment of a prudent layperson who 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 provide notice of the specific information we need to complete our
review of the claim. We will allow you up to 48 hours from the receipt of this notice to
provide the necessary 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.
• Urgent care claims
19 2013 Coventry Health Care Section 3
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 800-833-7423. You may also call OPM's Health Insurance 3 at 202-606-0737
between 8am and 5pm 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, then call us at 800-833-7423. If it is
determined that your claim is an urgent care claim, we will hasten our review (if we have
not yet responded to your claim).
If you have an emergency admission due to a condition that you reasonably believe puts
your life in danger or could cause serious damage to bodily function, you, your
representative, the physician, or the hospital must telephone us within two business days
following the day of the emergency admission, even if you have been discharged from the
hospital.
• Emergency inpatient
admission
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, then we will
make a decision within 24 hours after we receive the claim.
• If your treatment
needs to be extended
If the Member does not follow the requirements and his/her provider does not call Us,
benefits will be denied.
What happens when you
do not follow the
precertification rules
when using non-network
facilities
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.
Circumstances beyond
our control
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 detail below.
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.
If you disagree with our
pre-service claim decision
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 of 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 a non-
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.
• To reconsider an
urgent care claim
20 2013 Coventry Health Care Section 3
Subject to a request for additional information, we will notify you of our decision within
72 hours after receipt of your reconsideration request. We will hasten 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.
• To file an appeal with
OPM
21 2013 Coventry Health Care Section 3
Section 4. Your costs for covered services
You must share the cost of some service. You are responsible for:
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.
Cost-sharing
A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when
you receive services.
High Option and Standard Option: Example: when you see your primary care physician you
pay a copayment of $20 per office visit – and when you visit a specialist the copayment is $40
per visit. Preventive services do not require a copayment.
Copayments
A deductible is a fixed amount you must incur for certain covered services and supplies before
we pay benefits for them. Copayments do not count toward any deductible.
High Option: We have no deductible under the High Option plan.
Standard Option: The deductible amount for this plan is $300 for individual coverage and
$600 for family coverage. The Plan will not pay benefits until the deductible is met. The time
period for accumulating amounts applied to the deductible is a Calendar or Contract Year.
When the Member incurs expenses in the last three (3) months of a year which are applied to the
Member’s deductible for that year, the deductible amounts are also applied to the Member’s
deductible amount due for the following year, if the prior year deductible has not been satisfied
in full.
High Deductible Health Plan: The deductible amount for this plan is $2,000 for individual
coverage (subscribers covering no spouse or dependents) and $4,000 for family coverage
(subscribers covering spouse and/or family).
The Plan will not pay benefits until the deductible is met. The time period for accumulating
amounts applied to the deductible is a Calendar or Contract Year. The entire family deductible
must be met before individual family members are eligible for benefits.
Note: If you change plans during Open Season, you do not have to start a new deductible under
your old 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.
Deductible
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.
High Option: Example: you pay 20% of our allowance for durable medical equipment.
Standard Option: Example: you pay 20% of our allowance after your deductible for speech
therapy.
High Deductible Health Plan: Example: you pay nothing for durable medical equipment after
you have met the deductible in network and 30% of our allowance for durable medical
equipment after you have met the deductible out of network.
Note: If your provider routinely waives (does not require you to pay) your copayments,
deductibles, or coinsurance, the provider is misstating the fee and may be violating the law. In
this case, when we calculate our share, we will reduce the provider’s fee by the amount waived.
For example, if your physician ordinarily charges $100 for a service but routinely waives your
15% coinsurance, the actual charge is $70. We will pay $59.50 (85% of the actual charge of
$70).
Coinsurance
22 2013 Coventry Health Care Section 4
In-network providers agree to limit what they will bill you. Because of that, when you use a
network provider, your share of covered charges consists only of your deductible and
coinsurance or copayment. Here is an example about coinsurance: You see a network physician
who charges $150, but our allowance is $100. If you have met your deductible, you are only
responsible for your coinsurance. That is, you pay just – 15% of our $100 allowance ($15).
Because of the agreement, your network physician will not bill you for the $50 difference
between our allowance and his bill.
Differences between
our Plan allowance
and the bill
High Option: After your copayments and coinsurances total $1,000 per person or $3,000 per
family enrollment in any calendar year, you do not have to pay any more for covered services.
The calendar year out-of-pocket maximum does not include any copayments except those for
emergency room or urgent care center. In addition, coinsurances for infertility treatment do not
count toward your catastrophic protection out-of-pocket maximum, and you must continue to
pay coinsurance for these services.
Be sure to keep accurate records of your copayments and coinsurances since you are responsible
for informing us when you reach the maximum.
Standard Option: After your coinsurances total $3,000 per person or $9,000 per family
enrollment in any calendar year, you do not have to pay any more for covered services. The
calendar year out-of-pocket maximum does not include any deductibles or copayments except
those for emergency room or urgent care center. In addition, coinsurances for infertility
treatment do not count toward your catastrophic protection out-of-pocket maximum, and you
must continue to pay coinsurance for these services.
High Deductible Health Plan: Your out-of pocket maximum for this plan is $4,000 per
individual and $8,000 per family.
The individual Out-of-Pocket Maximum is a limit on the amount you must pay out of Your
pocket for specific Covered Services in a calendar year. The family Out-of-Pocket Maximum is
the limit on the total amount Members of the same family must pay for specific Covered
Services in a calendar year. Once the Out-of-Pocket Maximum is met, Covered Services are
paid at 100% for the remainder of the calendar year.
The out of pocket maximum includes all deductibles, copayments and coinsurance as applied by
this plan.
Your catastrophic
protection out-of-
pocket maximum
If you changed to this Plan during open season from a plan with a catastrophic protection benefit
and the effective date of the change was after January 1, any expenses that would have applied
to that plan’s catastrophic protection benefit during the prior year will be covered by your old
plan if they are for care you received in January before your effective date of coverage in this
Plan. If you have already met your old plan’s catastrophic protection benefit level in full, it will
continue to apply until the effective date of your coverage in this Plan. If you have not met this
expense level in full, your old plan will first apply your covered out-of-pocket expenses until the
prior year’s catastrophic level is reached and then apply the catastrophic protection benefit to
covered out-of-pocket expenses incurred from that point until the effective date of your coverage
in this Plan. Your old plan will pay these covered expenses according to this year’s benefits;
benefit changes are effective January 1.
Note: If you change options in this Plan during the year, we will credit the amount of covered
expenses already accumulated toward the catastrophic out-of-pocket limit of your old option to
the catastrophic protection limit of your new option.
Carryover
Facilities of the Department of Veteran 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.
When Government
facilities bill us
23 2013 Coventry Health Care Section 4
High and Standard Option Benefits
High and Standard Option
See page 10 for how our benefits changed this year. Page 123 and page 124 are a benefits summary of each option. Make
sure that you review the benefits that are available under the option in which you are enrolled.
Section 5. High and Standard Option Benefits Overview ..........................................................................................................26
Section 5(a). Medical services and supplies provided by physicians and other health care professionals .................................27
Diagnostic and treatment services .....................................................................................................................................27
Lab, X-ray and other diagnostic tests ................................................................................................................................28
Preventive care, adult ........................................................................................................................................................28
Preventive care, children ...................................................................................................................................................29
Maternity care ...................................................................................................................................................................29
Family planning ................................................................................................................................................................30
Infertility services .............................................................................................................................................................31
Allergy care .......................................................................................................................................................................31
Treatment therapies ...........................................................................................................................................................32
Physical and occupational therapies .................................................................................................................................32
Speech therapy ..................................................................................................................................................................33
Hearing services (testing, treatment, and supplies) ...........................................................................................................33
Vision services (testing, treatment, and supplies) .............................................................................................................34
Foot care ............................................................................................................................................................................34
Orthopedic and prosthetic devices ....................................................................................................................................34
Durable Medical Equipment (DME) .................................................................................................................................35
Home health services ........................................................................................................................................................36
Chiropractic .......................................................................................................................................................................36
Alternative treatments .......................................................................................................................................................36
Educational classes and programs .....................................................................................................................................36
Section 5(b). Surgical and anesthesia services provided by physicians and other health care professionals .............................38
Surgical procedures ...........................................................................................................................................................38
Reconstructive surgery ......................................................................................................................................................40
Oral and maxillofacial surgery ..........................................................................................................................................40
Organ/tissue transplants ....................................................................................................................................................41
Anesthesia .........................................................................................................................................................................45
Section 5(c). Services provided by a hospital or other facility, and ambulance services ...........................................................46
Inpatient hospital ...............................................................................................................................................................46
Outpatient hospital or ambulatory surgical center ............................................................................................................47
Extended care benefits/Skilled nursing care facility benefits ...........................................................................................47
Hospice care ......................................................................................................................................................................47
Ambulance ........................................................................................................................................................................48
Section 5(d). Emergency services/accidents ...............................................................................................................................49
Emergency within our service area ...................................................................................................................................50
Emergency outside our service area ..................................................................................................................................50
Ambulance ........................................................................................................................................................................50
Section 5(e). Mental health and substance abuse benefits ..........................................................................................................51
Professional Services ........................................................................................................................................................51
Diagnostics ........................................................................................................................................................................52
Inpatient hospital and other covered facility .....................................................................................................................52
Outpatient hospital or other covered facility .....................................................................................................................52
Section 5(f). Prescription drug benefits ......................................................................................................................................53
24 2013 Coventry Health Care High and Standard Option Section 5
High and Standard Option
Covered medications and supplies ....................................................................................................................................55
Section 5(g). Dental benefits .......................................................................................................................................................57
Accidental injury benefit ...................................................................................................................................................57
Dental Benefits ..................................................................................................................................................................57
Section 5(h). Special features ......................................................................................................................................................58
Flexible benefits option .....................................................................................................................................................58
Wellness Programs ............................................................................................................................................................58
Travel benefit/services overseas .......................................................................................................................................59
Summary of benefits for the High Option of Coventry Health Care - 2013 .............................................................................125
Summary of benefits for the Standard Option of Coventry Health Care - 2013 ......................................................................127
25 2013 Coventry Health Care High and Standard Option Section 5
Section 5. High and Standard Option Benefits Overview
High and Standard Option
This Plan offers both a High and Standard Option. Our benefit package is described in Section 5. Make sure that you review
the benefits carefully.
The High and Standard Option Section 5 is divided into subsections. Please read
Important things you should keep in mind
at
the beginning of the subsections. Also read the General exclusions in Section 6, they apply to the benefits in the following
subsections. To obtain claim forms, claims filing advice, or more information about High Option benefits, contact us at
800-833-7423 or at our Web site at www.chcde.com.
Our benefit package offers the following unique features:
The High Option is an individual practice health maintenance organization (HMO) plan.
We require you to see specific physicians, hospitals, and other providers that contract with
us. These Plan providers coordinate your health care services. The Plan is solely
responsible for the selection of these providers in your area. Contact the Plan for a copy
of their most recent provider directory.
HMOs emphasize preventive care such as routine office visits, physical exams, well-baby
care, and immunizations, in addition to treatment for illness and injury. Our providers
follow generally accepted medical practice when prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms
or pay bills. You pay only the copayments, coinsurance, and deductibles described in this
brochure. When you receive emergency services from non-Plan providers, you may have
to submit claim forms.
• High Option
The Standard Option HMO works similarly to the High Option plans, however the
benefits are not as rich, but the premiums are lower. Members use the same provider
network and preventive care is emphasized. However, some services will be subject to a
deductible and coinsurance. Basic care, such as, office visits, laboratory and x-rays, are
not subject to the deductible and have only a minimal copayment.
• Standard Option
26 2013 Coventry Health Care High and Standard Option Section 5 Overview
Section 5(a). Medical services and supplies
provided by physicians and other health care professionals
High and Standard Option
Important things you should keep in mind about these benefits:
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.
•Plan physicians must provide or arrange your care.
•A facility copay applies to services that appear in this section but are performed in an ambulatory
surgical center or the outpatient department of a hospital.
•High Option: We have no deductible.
•Standard Option: The calendar year deductible is: $300 per person ($600 per family). The calendar
year deductible applies to almost all benefits in this section. Copayments do not count toward your
deductible. Note: We added “(No deductible)” to show when the calendar year deductible does
not apply.
•Be sure to read Section 4,
Your costs for covered services
, for valuable information about how cost-
sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with
Medicare.
Benefit Description
Diagnostic and treatment services High Option Standard Option
Professional services of physicians
• In physician’s office
$20 copayment per visit to a
primary care physician (PCP)
$40 copayment per visit to a
specialist
$20 copayment per visit to a
primary care physician (PCP)
(No deductible)
$40 copayment per visit to a
specialist (No deductible)
Professional services of physicians
• In an urgent care center
• During a hospital stay
• In a skilled nursing facility
• Office medical consultation
• Second surgical opinion
Nothing
Nothing
Nothing
$20 PCP; $40 Specialist
$40 for specialist visit
Nothing
Nothing
Nothing
$20 PCP; $40 Specialist (No
deductible)
$40 for specialist visit (No
deductible)
At home Nothing Nothing
Not covered:
•
Immunizations needed for travel.
All charges All charges
27 2013 Coventry Health Care High and Standard Option Section 5(a)
High and Standard Option
Benefit Description
Lab, X-ray and other diagnostic tests High Option Standard Option
Tests, such as:
• Blood tests
• Urinalysis
• Non-routine Pap tests
• Pathology
• X-rays
Nothing if you receive any of
these services during your
office visit; otherwise, $10 per
office visit
Nothing if you receive any of
these services during your
office visit; otherwise, $10
copayment for lab tests (No
deductible)/$20 copayment for
x-rays (No deductible)
• CAT Scans/MRI
• Ultrasound
• Electrocardiogram and EEG
$50 copayment for high-tech
radiology services (i.e. MRI,
MRA, PET, and CAT scans)
20% coinsurance for
specialized radiology (MRI,
MRA, CAT & PET Scans)
Preventive care, adult High Option Standard Option
Routine physical every year which includes:
• Total Blood Cholesterol
• Colorectal Cancer Screening, including
- Fecal occult blood test
- Sigmoidoscopy, screening – every five years
starting at age 50
- Double contrast barium enema – every five
years starting at age 50
- Colonoscopy screening – every ten years starting
at age 50
Nothing Nothing
Routine Prostate Specific Antigen (PSA) test – one
annually for men age 40 and older
Annual Chlamydia Screening Test for women who
are younger than 20 years old who are sexually
active, and at least 20 years old who have multiple
risk factors; and men who have multiple risk factors.
Nothing Nothing
Well woman-one annually; including, but not limited
to:
• Routine pap test
• Human papillomavirus testing for women age 30
and up once every three years
• Counseling for sexually transmitted infections on
an annual basis.
• Counseling and screening for human immune-
deficiency virus on an annual basis.
• Contraceptive methods and counseling as
prescribed
• Screening and counseling for interpersonal and
domestic violence.
Nothing Nothing
Routine mammogram – covered for women age 35
and older, as follows:
Nothing Nothing
Preventive care, adult - continued on next page
28 2013 Coventry Health Care High and Standard Option Section 5(a)
High and Standard Option
Benefit Description
Preventive care, adult (cont.) High Option Standard Option
• From age 35 through 39, one during this five year
period
• From age 40 through 64, one every calendar year
• At age 65 and older, one every two consecutive
calendar years
Nothing Nothing
• Adult routine immunizations endoresed by the
Centers for Disease Control and Prevention (CDC)
Nothing Nothing
Not covered: Physical exams and immunizations
required for obtaining or continuing employment or
insurance, attending schools or camp, or travel.
All charges All charges
Preventive care, children High Option Standard Option
• Childhood immunizations recommended by the
American Academy of Pediatrics
Nothing Nothing
• Well-child care charges for routine examinations,
immunizations and care (up to age 22)
• Examinations, such as:
- Eye exams through age 17 to determine the need
for vision correction
- Hearing exams through age 17 to determine the
need for hearing correction
- Examinations done on the day of immunizations
(up to age 22)
Nothing Nothing
Maternity care High Option Standard Option
Complete maternity (obstetrical) care, such as:
• Prenatal care
• Screening for gestational diabetes for pregnant
women between 24-28 weeks gestation or first
prenatal visit for women at a high risk.
• Delivery
• Postnatal care
$20 copayment for the initial
office visit; Nothing for all
visits thereafter.
$20 copayment for the initial
office visit; Nothing for all
visits thereafter (No
deductible).
Breastfeeding support, supplies and counseling for
each birth
Nothing Nothing
Not covered:
•
Newborn home delivery
•
Surrogate motherhood services and supplies,
including, but not limited to, all services and
supplies relating to the conception and pregnancy
of a Member acting as a surrogate mother.
All charges All charges
Note: Here are some things to keep in mind:
Maternity care - continued on next page
29 2013 Coventry Health Care High and Standard Option Section 5(a)
High and Standard Option
Benefit Description
Maternity care (cont.) High Option Standard Option
• You do not need to precertify your normal delivery;
see below for other circumstances, such as
extended stays for you or your baby.
• You may remain in the hospital up to 48 hours after
a regular delivery and 96 hours after a cesarean
delivery. We will extend your inpatient stay if
medically necessary; however, you will need to get
preauthorization for extended days.
• For a mother and newborn child who have a
Hospital stay of less than 48 hours for vaginal
delivery or 96 hours for cesarean section, benefits
are provided for one home visit to occur within 24
hours after discharge and an additional home visit
if prescribed by the attending provider.
• For a mother and newborn child who remain in the
Hospital for at least 48 or 96 hours of inpatient
hospitalization, we shall provide coverage for a
home visit if prescribed by the attending provider.
• 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 for the
first 31 days after birth. An enrollment form must
be completed to cover the infant under a Self and
Family enrollment after the 31 days if you do not
already have Self and Family coverage
.
Surgical
benefits, not maternity benefits, apply to
circumcision.
• If a mother is required to remain hospitalized after
childbirth for medical reasons and the mother
requests that the newborn remain in the Hospital,
we shall provide as part of the hospitalization
services, payment for the cost of additional
hospitalization for the newborn for up to 4 days.
• We pay hospitalization and surgeon services for
non-maternity care the same as for illness and
injury.
Family planning High Option Standard Option
Contraceptive counseling on an annual basis Nothing Nothing
A range of voluntary family planning services,
limited to:
• Voluntary sterilization (See Surgical procedures
Section 5 (b))
• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo
provera)
• Intrauterine devices (IUDs)
• Diaphragms
50% coinsurance 50% coinsurance
Family planning - continued on next page
30 2013 Coventry Health Care High and Standard Option Section 5(a)
High and Standard Option
Benefit Description
Family planning (cont.) High Option Standard Option
Note: We cover oral contraceptives under the
prescription drug benefit.
50% coinsurance 50% coinsurance
Not covered:
•
Reversal of voluntary surgical sterilization.
•
Surrogate motherhood services and supplies,
including, but not limited to, all services and
supplies relating to the conception and pregnancy
of a Member acting as a surrogate mother
•
Genetic counseling
All charges All charges
Infertility services High Option Standard Option
Diagnosis and treatment of infertility such as:
• Artificial insemination:
- Intravaginal insemination (IVI)
- Intracervical insemination (ICI)
- Iintrauterine insemination (IUI)
• Invitrofertilization - Limited to three attempts per
live birth and a maximum plan lifetime benefit of
$100,000
• Fertility drugs
Note: We cover injectible fertility drugs under
medical benefits and oral fertility drugs under the
prescription drug benefit.
50% coinsurance 50% coinsurance
Not covered:
•
Assisted reproductive technology (ART)
procedures, such as:
- Intracytoplasmic sperm injection (ICSI), unless
authorized as part of an approved IVF procedure
- in vivo fertilization in vivo fertilization including
but not limited to all forms of artificial
insemination procedures, such as Artificial
Insemination Donor (AID), Artificial Insemination
Homologous/ Husband (AIH) and Interuterine
Insemination (IUI); and cryopreservation and
storage of sperm, eggs and embryos.
•
Cost of donor egg
•
Cost of donor sperm
All charges All charges
Allergy care High Option Standard Option
• Testing and treatment $20 copayment per PCP visit $20 copayment per PCP visit
(No deductible)
Allergy injections $40 copayment per specialist
visit
$40 copayment per specialist
visit (No deductible)
Allergy serum Nothing Nothing
Not covered: Provocative food testing and sublingual
allergy desensitization
All charges All charges
31 2013 Coventry Health Care High and Standard Option Section 5(a)
High and Standard Option
Benefit Description
Treatment therapies High Option Standard Option
• 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 35.
• Respiratory and inhalation therapy
• Dialysis – hemodialysis and peritoneal dialysis
• Intravenous (IV)/Infusion Therapy – Home IV and
antibiotic therapy
• Growth hormone therapy (GHT)
Note:
• Growth hormone therapy medications listed on the
Self-Administered Injectable (SAI) formulary are
covered under the prescription drug benefit. All
other growth hormone therapy will be covered
under the medical benefit.
We only cover GHT when we preauthorize the
treatment. Call 877-215-4100 for preauthorization.
We will ask you to submit information that
establishes that the GHT is medically necessary. Ask
us to authorize GHT before you begin treatment. We
will only cover GHT services and related services and
supplies that we determine are medically necessary.
See
Other Services
under You need prior Plan
approval for certain services in Section 3.
$40 copayment per specialist
visit or outpatient visit
Nothing per visit during
covered inpatient admission
$40 copayment per specialist
office visit (No deductible)
20% coinsurance per outpatient
facility service
Physical and occupational therapies High Option Standard Option
60 visits per condition per calendar year for the
services of each of the following:
• Qualified Physical Therapists
• Occupational Therapists
Note: We only cover therapy to restore bodily
function when there has been a total or partial loss of
bodily function due to illness or injury.
Cardiac rehabilitation following a heart transplant,
bypass surgery or a myocardial infarction is provided
for up to 60 sessions.
$40 copayment per visit
Nothing per visit during
covered inpatient admission
20% coinsurance per visit
Not covered:
•
Long-term rehabilitative therapy
•
Exercise programs
All charges All charges
32 2013 Coventry Health Care High and Standard Option Section 5(a)
High and Standard Option
Benefit Description
Speech therapy High Option Standard Option
60 visits per condition $40 copayment per visit
Nothing per visit during
covered inpatient admission
20% coinsurance per visit
Habilitative services High Option Standard Option
Habilitative services for the treatment of a child with
congenital or genetic birth defects to enhance the
child’s ability to function are covered for children
under the age of 19 if preauthorized by us. Services
include
• occupational,
• physical, and
• speech therapy
$40 copayment per visit 20% coinsurance per visit
Not covered
•
Habilitative services delivered through early
intervention or school services
All charges All charges
Hearing services (testing, treatment, and
supplies)
High Option Standard Option
First hearing aid and testing only when necessitated
by accidental injury
$20 copayment PCP visit
$40 copayment specialist visit
$20 copayment PCP visit (No
deductible)
$40 copayment specialist visit
(No deductible)
Hearing testing for children through age 17, which
include; (see
Preventive care, chrildren)
Nothing Nothing
• Hearing aids for minor children up to a maximum
Plan benefit of $1,400 per hearing aid per every 36
months when a hearing aid is prescribed, fitted and
dispensed by a licensed audiologist.
• Hearing aids for adults up to a maximum Plan
benefit of $500 per hearing aid per every 5 years
when a hearing aid is prescribed, fitted and
dispensed by a licensed audiologist.
20% coinsurance 20% coinsurance
Not covered:
•
Hearing services that are not shown as covered.
All charges All charges
33 2013 Coventry Health Care High and Standard Option Section 5(a)
High and Standard Option
Benefit Description
Vision services (testing, treatment, and
supplies)
High Option Standard Option
• Eye exam to determine the need for vision
correction for children though age 17
• First pair of eyeglasses or corrective lenses
required following cataract surgery
Note: See
Preventive care, children
for eye exams for
children.
Nothing
20% coinsurance for eyeglasses
or corrective lenses
Nothing
20% coinsurance for eyeglasses
or corrective lenses
Not covered:
•
Eyeglasses or contact lenses, except as shown
above
•
Eye exercises and orthoptics
•
Radial keratotomy and other refractive surgery
•
Annual Refraction
All charges All charges
Foot care High Option Standard Option
Routine foot care when you are under active
treatment for a metabolic or peripheral vascular
disease, such as diabetes. Visits to a podiatrist are
limited to 10 visits per calendar year.
$40 copayment per specialist
visit
$40 copayment per specialist
visit (No deductible)
Not covered:
•
Cutting, trimming or removal of corns, calluses, or
the free edge of toenails, and similar routine
treatment of conditions of the foot, except as stated
above
•
Treatment of weak, strained or flat feet or bunions
or spurs; and of any instability, imbalance or
subluxation of the foot (unless the treatment is by
open cutting surgery)
All charges All charges
Orthopedic and prosthetic devices High Option Standard Option
• Artificial limbs and eyes
• Stump hose
• Externally worn breast prostheses and surgical
bras, including necessary replacements following a
mastectomy
• Hearing aids and testing to fit them (for details
refer to Hearing Services, page 28)
• Internal prosthetic devices, such as artificial joints,
pacemakers, cochlear implants, 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 and anesthesia services. 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% coinsurance 20% coinsurance
Orthopedic and prosthetic devices - continued on next page
34 2013 Coventry Health Care High and Standard Option Section 5(a)
High and Standard Option
Benefit Description
Orthopedic and prosthetic devices (cont.) High Option Standard Option
• Internal prosthetic devices are paid as hospital
benefits; see Section 5(c) for payment information.
Insertion of the device is paid as surgery; see
Section 5(b) for coverage of the surgery to insert
the device.
• Corrective orthopedic appliances for non-dental
treatment of temporomandibular joint (TMJ) pain
dysfunction syndrome.
• Prosthetic replacements are provided when
preauthorized.
20% coinsurance 20% coinsurance
Not covered:
•
Orthopedic and corrective shoes, a rch supports,
f oot orthotics, h eel pads and heel cups
•
Lumbosacral supports
•
Corsets, trusses, elastic stockings, support hose,
and other supportive devices
•
Prosthetic replacements that are not preauthorized.
•
Braces and supports needed for athletic
participation or employment.
All charges All charges
Durable Medical Equipment (DME) High Option Standard Option
Rental or purchase, at our option, including repair and
adjustment, of durable medical equipment prescribed
by your Plan physician, such as oxygen and dialysis
equipment. Under this benefit, we also cover:
• Hospital beds
• Wheelchairs (see note below regarding motorized
wheelchairs)
• Crutches
• Walkers
• Ostomy and disposable diabetic supplies
• Hair prosthesis as prescribed by the attending
oncologist for a member who hair loss is a result of
chemotherapy or radiation treatment for cancer
(Coverage is limited to a maximum Plan benefit of
$350 for one hair prosthesis)
• Blood glucose monitors
• Insulin pumps
20% coinsurance 20% coinsurance
Not covered: Motorized wheelchair, wigs (except as
noted above), and upgrades to equipment.
All charges All charges
35 2013 Coventry Health Care High and Standard Option Section 5(a)
High and Standard Option
Benefit Description
Home health services High Option Standard Option
• home health care 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.
• home visits following a mastectomy or removal of
a testicle if the hospital stay is less than 48 hours.
• services include oxygen therapy, intravenous
therapy and medications.
Nothing 20% coinsurance
Not covered:
•
nursing care requested by, or for the convenience
of, the patient or the patient’s family.
•
home care primarily for personal assistance that
does not include a medical component and is not
diagnostic, therapeutic, or rehabilitative.
All charges All charges
Chiropractic High Option Standard Option
• Coverage is limited to 20 visits per calendar year.
Services include consultation, diagnosis, and
treatment of diseases relating to subluxations of the
articulations of the spine and adjacent tissues.
$40 copayment per visit 20% coinsurance
Alternative treatments High Option Standard Option
No benefit All charges All charges
Educational classes and programs High Option Standard Option
• Diabetic outpatient self-management training and
education
• Health Education such as instructions on achieving
and maintaining physical and mental health, and
preventing illness and injury and childhood obesity
education.
• Nutritional counseling provided by a Registered
Dietician or Participating Physician in connection
with diabetes, coronary artery disease and
hyperlipidemia.
Nothing Nothing
Tobacco cessation programs, including individual/
group/telephone counseling, and for over the counter
(OTC) and prescription drugs approved by the FDA
to treat tobacco dependence.
Nothing for up to two quit
attempts per year.
Nothing for OTC and
prescription drugs approved by
the FDA to treat tobacco
dependence.
Nothing for up to two quit
attempts per year.
Nothing for OTC and
prescription drugs approved by
the FDA to treat tobacco
dependence.
36 2013 Coventry Health Care High and Standard Option Section 5(a)
High and Standard Option
Benefit Description
Medical Clinical Trial High Option Standard Option
If you are a participant in a clinical trial, we will
provide related care if it is not provided by the
clinical trial, as follows:
We provide coverage for Routine Patient Care Cost to
a Member in a Medical Clinical Trial for randomized
and controlled Phase III treatment of a life
threatening disease, if such expenses are covered
under this agreement, and we authorize them in
advance.
We provide coverage for Phase I and Phase II clinical
trials and any randomized and controlled clinical trial
for treatment of cancer that are sanctioned by the
National Cancer Institute (NCI), or for the cost of any
investigational drug.
Treatment in a Medical Clinical Trial must be
authorized in advance by us.
See coverage limitations based
on setting (Inpatient, page 40;
Outpatient, page 41; Home,
page 22 and Office, page 22,
etc.), and type of provider
(Specialist care in office,
hospital, etc.)
See coverage limitations based
on setting (Inpatient, page 40;
Outpatient, page 41; Home,
page 22 and Office, page 22,
etc.), and type of provider
(Specialist care in office,
hospital, etc.)
37 2013 Coventry Health Care High and Standard Option Section 5(a)
Section 5(b). Surgical and anesthesia services provided by physicians and other
health care professionals
High and Standard Option
Important things you should keep in mind about these benefits:
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.
•Plan physicians must provide or arrange your care.
•High Option: We have no deductible.
•Standard Option: The calendar year deductible is: $300 per person ($600 per family). The calendar
year deductible only applies to the Standard Option Plan. Copayments do not apply towards the
deductible. Note: The calendar year deductible applies to almost all benefits in this Section.
We say “(No deductible)” when it does not apply.
•Be sure to read Section 4,
Your costs for covered services
, for valuable information about how cost-
sharing works. Also read Section 9 about coordinating benefits with other coverage, including with
Medicare.
•The amounts listed below are for the charges billed by a physician or other health care professional
for your surgical care. Look in Section 5(c) for charges associated with the facility (i.e. hospital,
surgical center, etc.).
•YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME SURGICAL
PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure
which services require precertification and identify which surgeries require precertification.
Benefit Description
Surgical procedures High Option Standard Option
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)
• Treatment of burns
$20 copayment for surgeries in
a primary care physician office
$40 copayment for surgeries in
a specialist office
Nothing for facility visits
$20 copayment for surgeries in
a primary care physician office
(No deductible)
$40 copayment for surgeries in
a specialist office (No
deductible)
20% for facility visits
Surgical procedures - continued on next page
38 2013 Coventry Health Care High and Standard Option Section 5(b)
High and Standard Option
Benefit Description
Surgical procedures (cont.) High Option Standard Option
• Surgical treatment of morbid obesity (Bariatric
Surgery), see
Services requiring our prior approval
on page 11.
- a condition in which an individual weighs 100
pounds or 100% over his or her normal weight
according to current underwriting standards;
eligible members must be age 18 or over.
- When we approve, we provide coverage for
treatment of morbid obesity through gastric bypass
surgery or another surgical method that is
recognized by the National Institutes of Health as
effective for the long-term reversal of morbid
obesity and consistent with criteria approved by the
National Institutes of Health.
- We provide benefits like any other medically
necessary surgical procedure for Members whose
body mass index is greater than 40 kilograms per
meter squared, or equal to or greater than 35
kilograms per meter squared with a comorbid
medical condition including hypertension,
cardiopulmonary condition, sleep apnea or
diabetes.
- Body mass index is calculated by dividing the
Member’s weight in kilograms by the Member’s
height in meters squared.
• Insertion of internal prosthetic devices. See 5(a) -
Orthopedic and prosthetic devices
for device
coverage information
Note: Generally, we pay for internal prostheses
(devices) according to where the procedure is done.
For example, we pay Hospital benefits for a
pacemaker and Surgery benefits for insertion of the
pacemaker.
$20 copayment for surgeries in
a primary care physician office
$40 copayment for surgeries in
a specialist office
Nothing for facility visits
$20 copayment for surgeries in
a primary care physician office
(No deductible)
$40 copayment for surgeries in
a specialist office (No
deductible)
20% for facility visits
• Voluntary sterilization (e.g. tubal ligation,
vasectomy)
50% coinsurance 50% coinsurance
Not covered:
•
Reversal of voluntary sterilization
•
Routine treatment of conditions of the foot; see
Foot care
All charges All charges
39 2013 Coventry Health Care High and Standard Option Section 5(b)
High and Standard Option
Benefit Description
Reconstructive surgery High Option Standard Option
• 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.
• 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
• All stages of breast reconstruction surgery
following a mastectomy, such as:
- surgery to produce a symmetrical appearance of
breasts;
- treatment of any physical complications, such as
lymphedemas;breast prostheses and surgical bras
and replacements (see
Prosthetic devices
)
Note: If you need a mastectomy, you may choose to
have the procedure performed on an inpatient basis
and remain in the hospital up to 48 hours after the
procedure.
$20 copayment for surgeries in
a primary care physician office;
$40 copayment for surgeries in
a specialist office
When you have surgery in an
inpatient or outpatient facility
there is no copayment for the
physician’s services; however,
copayments and coinsurance
apply to the facility’s charges.
$20 copayment for surgeries in
a primary care physician office
(No deductible)
$40 copayment for surgeries in
a specialist office (No
deductible)
20% coinsurance for surgeries
in a free-standing surgi-center
or outpatient hospital
Not covered:
•
Cosmetic surgery – any surgical procedure (or any
portion of a procedure) performed primarily to
improve physical appearance through change in
bodily form, except repair of accidental injury
•
Surgeries related to sex transformation
All charges All charges
Oral and maxillofacial surgery High Option Standard Option
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
• TMJ related services (non-dental);
• Excision of cysts and incision of abscesses when
done as independent procedures; and
• Other surgical procedures that do not involve the
teeth or their supporting structures.
$20 copayment for surgeries in
a primary care physician office;
$40 copayment for surgeries in
a specialist office
When you have surgery in an
inpatient or outpatient facility
there is no copayment for the
physician’s services; however,
copayments and coinsurance
apply to the facility’s charges.
$20 copayment for surgeries in
a primary care physician office
(No deductible)
$40 copayment for surgeries in
a specialist office (No
deductible)
20% coinsurance for surgeries
in a free-standing surgi-center
or outpatient hospital
Oral and maxillofacial surgery - continued on next page
40 2013 Coventry Health Care High and Standard Option Section 5(b)
High and Standard Option
Benefit Description
Oral and maxillofacial surgery (cont.) High Option Standard Option
Not covered:
•
Oral implants and transplants
•
Procedures that involve the teeth or their
supporting structures (such as the periodontal
membrane, gingiva, and alveolar bone)
All charges All charges
Organ/tissue transplants High Option Standard Option
These solid organ transplants are subject to medical
neccessity and experimental/investigational review by
the Plan. Refer to
Other services
in Section 3 for
prior authorization procedures. Transplant services
must be performed at a participating Center of
Excellence. We approve and designate where all
transplants must be performed including hospitals for
specific transplant procedures. If you would like to
know about a specific facility, please contact
Customer Service.
Solid organ transplants limited to:
• Cornea
• Heart
• Heart/lung
• Kidney
• Kidney/Pancreas
• Liver
• Lung: single/bilateral/lobar
• Pancreas
• Autologous pancreas islet cell transplant (as an
adjunct to total or near total pancreatectomy) only
for patients with chronic pancreatitis
• Intestinal transplants
- Small intestine
- Small intestine with liver
- Small intestine with multiple organs , such as the
liver, stomach, and pancreas
Nothing Nothing
Blood or marrow stem cell transplants limited to the
stages of the following diagnoses: (the medical
necessity limitation is considered satisfied if the
patient meets the staging description)
• Allogeneic transplants for
- Acute lymphocytic or non-lymphocytic (i.e.,
myelogeneous) leukemia
- Chronic lymphocytic leukemia/small
lymphocytic lymphoma (CLL/SLL)
- Advanced Hodgkin’s lymphoma with
reoccurrence
Nothing Nothing
Organ/tissue transplants - continued on next page
41 2013 Coventry Health Care High and Standard Option Section 5(b)
High and Standard Option
Benefit Description
Organ/tissue transplants (cont.) High Option Standard Option
- Advanced non-Hodgkin’s lymphoma with
reoccurrence
- Marrow Failure and Related disorders (i.e.
Fanconi's PNH, pure red cell aplasia)
- Chronic myleogenous leukemia
- Hemoglobinopathies
- Myelodysplasia/Myelodysplastic syndromes
- Severe combined immunodeficiency
- Severe or very severe aplastic anemia
- Amyloidosis
- Paroxysmal Nocturnal Hemoglobinuira
• Autologous transplants for
- Acute lymphocytic or nonlymphocytic (i.e.,
myelogenous) leukemia
- Advanced Hodgkin’s lymphoma with
reoccurrence
- Advanced non-Hodgkin’s lymphoma with
reoccurrence
- Neuroblastoma
- Amyloidosis
• Autologous tandem transplants for
- Recurrent germ cell tumors (including testicular
cancer)
- Multiple myeloma
- Denovo myeloma
Blood or marrow stem cell transplants for
• Allogeneic transplants for
- Phagocytic/Hemophagocytic deficiency diseases
(e.g., Wiskott-Aldrich syndrome)
- Advanced neuroblastoma
- Infantile malignant osteopetrosis
- Kostmann’s syndrome
- Leukocyte adhesion deficiencies
- Mucolipidosis (e.g., Gaucher’s disease,
metachromatic leukodystrophy,
adrenoleukodystrophy
- Mucopolysaccharidosis (e.g., Hunter’s
syndrome, Hurler’s syndrome, Sanfilippo’s
syndrome, Maroteaux-Lamy syndrome variants)
- Myeloproliferative disorder
- Sickle cell anemia
Nothing Nothing
Organ/tissue transplants - continued on next page
42 2013 Coventry Health Care High and Standard Option Section 5(b)
High and Standard Option
Benefit Description
Organ/tissue transplants (cont.) High Option Standard Option
- X-linked lymphoproliferative syndrome
• Autologous transplants for
- Multiple myeloma
- Testicular, mediastinal, retroperitoneal, and
ovarian germ cell tumors
- Breast cancer
- Epithelial ovarian cancer
- Ependymoblastoma
- Ewing’s sarcoma
- Medulloblastoma
- Pineoblastoma
- Waldenstrom's macroglobulinemia
Nothing Nothing
Mini-transplants (nonmyeloblative, reduced intensity
conditioning) for covered transplants: Subject to
medical necessity. Refer to
Other Services
in Section
3 for prior authorization procedures.
Nothing Nothing
Tandem transplants for covered transplants: Subject
to medical necessity. Refer to
Other Services
in
Section 3 for prior authorization procedures.
Nothing Nothing
These Bone or marrow stem cell transplants covered
only in a National Cancer Institute or National
Institutes of Health approved clinical trial or a Plan-
designated center of excellence and 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 neccessary (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
informaiton on costs related to clinical trials. We
encourage you to contact the Plan to disucss specific
services if you participate in a clinical trial.
• Allogeneic transplants for
- Chronic lymphocytic leukemia/small
lymphocytic lymphoma (CLL/SLL)
- Chronic inflammatory demyelination
polyneuropathy (CIPD)
- Hemoglobinopathies
- Early stage (indolent or non-advanced) small
cell lymphocytic lymphoma
- Myelodysplasia/Myelodysplastic syndromes
- Multiple myeloma
- Multiple sclerosis
Nothing Nothing
Organ/tissue transplants - continued on next page
43 2013 Coventry Health Care High and Standard Option Section 5(b)
High and Standard Option
Benefit Description
Organ/tissue transplants (cont.) High Option Standard Option
• Nonmyeloablative allogeneic transplants or
reduced intensity conditioning (RIC) for
- Acute lymphocytic or non-lymphocytic (i.e.,
myelogeneous) leukemia
- Myelodysplasia/Myelodysplastic syndromes
- Advanced Hodgkin’s lymphoma with
reoccurrence
- Advanced non-Hodgkin’s lymphoma with
reoccurence
- Breast cancer
- Chronic lymphocytic leukemia
- Chronic myelogenous leukemia
- Colon cancer
- Early stage (indolent or non-advanced) small
cell lymphocytic lymphoma
- Chronic lymphocytic leukemia/small
lymphocytic lymphoma (CLL/SLL)
- Multiple myeloma
- Multiple sclerosis
- Myeloproliferative disorder
- Non-small cell lung cancer
- Ovarian cancer
- Prostate cancer
- Renal cell carcinoma
- Sarcomas
- Sickle Cell disease
• Autologous transplants for
-Advanced Childhood kidney cancers
-Advanced Ewing sarcoma
-Advanced Hodgkin’s lymphoma
-Advanced non-Hodgkin’s lymphoma
-Breast Cancer
-Childhood rhabdomyosarcoma
-Chronic myelogenous leukemia
-Chronic lymphocytic lymphoma/small lymphocytic
lymphoma (CLL/SLL)
-Early stage (indolent or non-advanced) small cell
lymphocytic lymphoma
-Epithelial Ovarian Cancer
Nothing Nothing
Organ/tissue transplants - continued on next page
44 2013 Coventry Health Care High and Standard Option Section 5(b)
High and Standard Option
Benefit Description
Organ/tissue transplants (cont.) High Option Standard Option
-Mantle Cell (Non-Hodgkin lymphoma)
-Multiple sclerosis
-Small cell lung cancer
-Systemic lupus erythematosus
-Systemic sclerosis
• National Transplant Program (NTP) -
Note: We cover related medical and hospital expenses
of the donor when we cover the recipient. We cover
donor testing for the actual solid organ donor or up to
four bone marrow/stem cell transplant donors in
addition to the testing of family members.
Nothing Nothing
Not covered:
•
Implants of artificial organs
•
Transplants not listed as covered
All charges All charges
Anesthesia High Option Standard Option
Professional services provided in –
• Hospital (inpatient)
Nothing 20% coinsurance
Professional services provided in –
• Hospital outpatient department
• Skilled nursing facility
• Ambulatory surgical center
• Office
Nothing 20% coinsurance for outpatient
department of hospital, skilled
nursing facility and ambulatory
surgical-center
Nothing for office service (No
deductible)
45 2013 Coventry Health Care High and Standard Option Section 5(b)
Section 5(c). Services provided by a hospital or
other facility, and ambulance services
High and Standard Option
Important things you should keep in mind about these benefits:
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.
•Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.
•High Option: We have no deductible.
•Standard Option: The calendar year deductible is: $300 per person ($600 per family). The calendar
year deductible only applies to the Standard Option Plan. Copayments do not apply towards the
deductible. Note: The calendar year deductible applies only when we say below “(calendar year
deductible applies)”.
•Be sure to read Section 4,
Your costs for covered services
for valuable information about how cost-
sharing works. Also read Section 9 about coordinating benefits with other coverage, including with
Medicare.
•The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center)
or ambulance service for your surgery or care. Any costs associated with the professional charge (i.
e., physicians, etc.) are in Sections 5(a) or (b).
•YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR HOSPITAL STAYS. Please
refer to Section 3 to be sure which services require precertification.
Benefit Description
Inpatient hospital High Option Standard Option
Room and board, such as
• Ward, semiprivate, or intensive care
accommodations
• General nursing care
• Meals and special diets
Note: If you want a private room when it is not
medically necessary, you pay the additional charge
above the semiprivate room rate.
$200 copayment per day up to a
maximum of $600 per
admission
$200 copayment per day up to a
maximum of $600 per
admission (No deductible)
Other hospital services and supplies, such as:
• Operating, recovery, maternity, and other treatment
rooms
• Prescribed drugs and medicines
• Diagnostic laboratory tests and X-rays
• Dressings , splints , casts , and sterile tray services
• Medical supplies and equipment, including oxygen
Nothing Nothing
• Anesthetics, including nurse anesthetist services
• Take-home items
• Medical supplies, appliances, medical equipment,
and any covered items billed by a hospital for use
at home (Note: calendar year deductible applies.)
Nothing Nothing
Not covered: All charges All charges
Inpatient hospital - continued on next page
46 2013 Coventry Health Care High and Standard Option Section 5(c)
High and Standard Option
Benefit Description
Inpatient hospital (cont.) High Option Standard Option
•
Custodial care
•
Non-covered facilities, such as nursing homes,
schools
•
Personal comfort items, such as telephone,
television, barber services, guest meals and beds
•
Private nursing care
All charges All charges
Outpatient hospital or ambulatory surgical
center
High Option Standard Option
• Operating, recovery, and other treatment rooms
• Prescribed drugs and medicines
• Diagnostic laboratory tests, X-rays , and pathology
services
• Administration of blood, blood plasma, and other
biologicals
• Pre-surgical testing
• Dressings, casts , and sterile tray services
• Medical supplies, including oxygen
• Anesthetics and anesthesia service
Note: We cover hospital services and supplies related
to dental procedures when necessitated by a non-
dental physical impairment. We do not cover the
dental procedures.
$150 per visit to an ambulatory
surgical center
Nothing for surgery in an
outpatient department of a
hospital
20% coinsurance (Calendar
year deductible applies)
Not covered: Blood and blood derivatives not
replaced by the member
All charges All charges
Extended care benefits/Skilled nursing care
facility benefits
High Option Standard Option
Covered up to 100 days per calendar year when full-
time skilled nursing care is necessary, and
confinement in a skilled nursing facility is medically
appropriate as determined by a Plan doctor and
approved by the Plan.
$200 copayment per day up to a
maximum of $600 per
admission
$200 copay per day up to a
maximum of $600 per
admission (No deductible)
Not covered: custodial care All charges All charges
Hospice care High Option Standard Option
Authorized within the service area for 30 days of
inpatient care per member. Includes the following:
• Part-time nursing care by or supervised by a
registered graduate nurse;
• Counseling, including dietary counseling, for the
terminally ill Member,
• Family counseling for the Immediate Family and
the Family Caregiver before the death of the
terminally ill Member;
Nothing 20% coinsurance
Hospice care - continued on next page
47 2013 Coventry Health Care High and Standard Option Section 5(c)
High and Standard Option
Benefit Description
Hospice care (cont.) High Option Standard Option
• Bereavement counseling for the Immediate Family
or Family Caregiver of the Member for at least the
6-month period following the Member’s death or
15 visits, whichever occurs first;
• Respite Care subject to the following:
- The annual benefit shall be at least 14 days; and
- The carrier may limit any one inpatient stay for
Respite Care to 5 consecutive days; and
Medical supplies, equipment, and medication
required to maintain the comfort and manage the pain
of the terminally ill Member.
Nothing 20% coinsurance
Not covered: Independent nursing, homemaker
services
All charges All charges
Ambulance High Option Standard Option
Local professional ambulance service when
medically appropriate
Nothing 20% coinsurance
48 2013 Coventry Health Care High and Standard Option Section 5(c)
Section 5(d). Emergency services/accidents
High and Standard Option
Important things you should keep in mind about these benefits:
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.
•High Option: We have no deductible.
•Standard Option: The calendar year deductible is: $300 per person ($600 per family). The calendar
year deductible applies only to the Standard Option Plan. Copayments do not apply towards the
deductible. We added "No deductible" to show when the calendar year deductible does not
apply.
•Be sure to read Section 4,
Your costs for covered services,
for valuable information about how cost-
sharing works. Also read Section 9 about coordinating benefits with other coverage, including with
Medicare.
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or
could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies
because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are
emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or
sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies – what
they all have in common is the need for quick action.
What to do in case of emergency:
In a life-threatening emergency, call the local emergency system (e.g. the local 911-telephone system), or go to the nearest
emergency facility. If an ambulance comes, tell the paramedics that the person who needs help is a Coventry Health Care
member.
Emergencies within our service area:
When a need for Emergency Services occurs in the Service Area, a member should seek medical attention immediately from
a hospital, physician’s office or other emergency facility. The determination of covered benefits for services rendered in an
emergency facility is based on our review of the member’s emergency room medical records, along with those relevant
symptoms and circumstances that preceded the provision of care. Services provided by an emergency facility for non-
Emergency Services are not covered except if you are directed to an emergency room by us or a physician and the care is
deemed not to be an emergency. Coverage will also be provided for Emergency Services in cases where you do not have 24-
hour access to a physician, even if those services are deemed not to be an emergency.
Emergencies outside our service area:
The member may be transported from outside the service area to the service area for continued medical management of an
emergency services condition at the option of the Medical Director or Medical Director’s Designee. We will only exercise
this option when the Medical Director or Medical Director’s Designee decides that such action will not have a detrimental
effect on the Member’s medical condition. Ground ambulance transportation to return a member to a participating provider
is covered when authorized by us. Refusal to be transferred may result in loss of benefits.
49 2013 Coventry Health Care High and Standard Option Section 5(d)
High and Standard Option
Benefit Description
Emergency within our service area High Option Standard Option
Emergency care at a doctor’s office $20 copayment at primary care
physician office
$40 copayment at specialist
office
$20 copayment at primary care
physician office (No
deductible)
$40 copayment at specialist
office (No deductible)
Emergency care at an urgent care center $30 copayment per visit 20% coinsurance
Emergency care as an outpatient at a hospital,
including doctors' services
Note: We waive the ER copay if you are admitted to
the hospital
$150 copayment per visit 20% coinsurance
Not covered: Elective care or non-emergency care All charges All charges
Emergency outside our service area High Option Standard Option
Emergency care at a doctor’s office $20 copayment at primary care
physician office
$40 copayment at specialist
office
$20 copayment at primary care
physician office (No
deductible)
$40 copayment at specialist
office (No deductible)
Emergency care at an urgent care center $30 copayment per visit 20% coinsurance
Emergency care as an outpatient at a hospital,
including doctors' services
Note: We waive the ER copay if you are admitted to
the hospital.
$150 copayment per visit 20% coinsurance
Not covered:
•
Elective care or non-emergency care and follow-up
care recommended by non-Plan providers that has
not been approved by the Plan or provided by Plan
providers
•
Emergency care provided outside the service area
if the need for care could have been foreseen
before leaving the service area
•
Medical and hospital costs resulting from a normal
full-term delivery of a baby outside the service area
All charges All charges
Ambulance High Option Standard Option
Professional ambulance service when medically
appropriate.
Note: See 5(c) for non-emergency service.
Nothing 20% coinsurance
50 2013 Coventry Health Care High and Standard Option Section 5(d)
Section 5(e). Mental health and substance abuse benefits
High and Standard Option
You need to get our approval for services and follow a treatment plan we approve in order to get
benefits. When you receive services as part of an approved treatment plan, cost-sharing and
limitations for Plan mental health and substance abuse benefits will be no greater than for similar
benefits for other illnesses and conditions.
Important things you should keep in mind about these benefits:
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.
•The calendar year deductible or, for facility care, the inpatient deductible, applies to almost all
benefits in this Section. We added "(No deductible)" to show when a deductible does not apply.
•Be sure to read Section 4,
Your costs for covered services,
for valuable information about how cost-
sharing works. Also read Section 9 about coordinating benefits with other coverage, including with
Medicare.
•YOU MUST GET PREAUTHORIZATION FOR THESE SERVICES. Benefits are payable
only when we determine that care is clinically appropriate to treat your condition and only when you
receive the care as part of a treatment plan that we approve. The treatment plan may include
services, drugs, and supplies described elsewhere in this brochure. To be eligible to receive full
benefits, you must follow the preauthorization process and get Plan approval of your treatment plan.
We will provide medical review criteria or reasons for treatment plan denials to enrollees, members
or providers upon request or as otherwise required.
•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 plan in favor of another.
Benefit Description You Pay
Professional Services High Option Standard Option
When part of a treatment plan we approve, we cover
professional services by licensed professional mental
health and substance abuse practioners when acting
within the scope of their license, such as psychiatrists,
psychologists, clinical social workers, licensed
professional counselors, or marriage and family
therapists.
Diagnosis and treatment of psychiatric conditions,
mental illness, or mental discorders. Services
include:
• Diagnostic evaluation
• Crisis intervention and stabilization for acute
episodes
• Medication evaluation and management
(pharmacotherapy)
• Pyschological and neuropsychological testing
necessary to determine the appropriate psychiatric
treatment
• Treatment and counseling (including individual or
group therapy visits)
Inpatient-your cost-sharing
responsibilities are no greater
than for other illnesses or
conditions.
Outpatient-your cost share is 0
for services provided in an out-
patient setting.
Inpatient-your cost-sharing
responsibilities are no greater
than for other illnesses or
conditions.
Outpatient-your cost share is 0
for services provided in an out-
patient setting.
Professional Services - continued on next page
51 2013 Coventry Health Care High and Standard Option Section 5(e)
High and Standard Option
Benefit Description You Pay
Professional Services (cont.) High Option Standard Option
• Diagnostic and treatment of alcoholism and drug
abuse, including detoxification, treatment and
counseling
• Professional charges for intensive outpatient
treatment in a provider's office or other
professional setting
• Electroconvulsive therapy
Inpatient-your cost-sharing
responsibilities are no greater
than for other illnesses or
conditions.
Outpatient-your cost share is 0
for services provided in an out-
patient setting.
Inpatient-your cost-sharing
responsibilities are no greater
than for other illnesses or
conditions.
Outpatient-your cost share is 0
for services provided in an out-
patient setting.
Diagnostics High Option Standard Option
• Outpatient diagnostic tests provided and billed by a
licensed mental health and substance abuse
practitioner
• Outpatient diagnostic tests provided and billed by a
laboratory, hospital or other covered facility
• Inpatatient diagnostic tests provided and billed by a
hospital or other covered facility
$10 copayment for lab tests
Nothing for inpatient tests
$10 copayment for lab tests (No
deductible)
Nothing for inpatient tests
Inpatient hospital and other covered facility High Option Standard Option
Outpatient hospital or other covered facility High Option Standard Option
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
Not covered: Services we have not approved
Nothing for services provided
in an out-patient setting
Nothing for services provided
in an out-patient setting
To be eligible to receive these benefits you must obtain a treatment plan and follow all of
the following network authorization processes:
MHNet Behavioral Health is contracted by CHCDE to provide a network of providers
who offer a variety of therapeutic services on an inpatient and outpatient basis. All
inpatient and outpatient treatment must be authorized by MHNet at 866-808-2808 or
800-862-2244 (for the deaf and hard of hearing).
Preauthorization
We may limit your benefits if you do not obtain a treatment plan. Limitation
52 2013 Coventry Health Care High and Standard Option Section 5(e)
Section 5(f). Prescription drug benefits
High and Standard Option
Important things you should keep in mind about these benefits:
•We cover prescribed drugs and medications, as described in the chart beginning on the next page.
•Please remember that all benefits are subject to the definitions, limitations and exclusions in this
brochure and are payable only when we determine they are medically necessary.
•High and Standard Option: We have no calendar year deductible.
•Be sure to read Section 4,
Your costs for covered services,
for valuable information about how cost-
sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with
Medicare.
There are important features you should be aware of. These include:
•Who can write your prescription. You may obtain a prescription from a prescribing physician or other health care
professional who is licensed and who, in the usual course of business, may legally prescribe prescription drugs.
•Where you can obtain them. You may fill the prescription at a participating pharmacy, including a participating mail
order or specialty pharmacy, except for Emergency or Urgent Care Services, out of the service area. A “specialty
pharmacy” is a pharmacy from which you may obtain self-administered injectable drugs. You may obtain maintenance
medication through Medco Health Solutions, our mail order prescription program. Medco’s Customer Service number is
800-378-7040.
•We use a formulary. A formulary is a list of specific generic and brand name prescription drugs authorized by the Health
plan and subject to periodic review and modification. Since there may be more than one brand name of a prescription
drug, not all brands of the same prescription drug may be included in the formulary. If you would like information on
whether a specific drug is included in our drug formulary, please call our Customer Service Department at 302-283-6500
within our service area or 800-833-7423.
•Tier 1A formulary medications. Tier 1A is a list of specific generic medications that are available to you at a reduced
copayment. To view and download the specific list of Tier 1A medications, go to www.chcde.com, plan members, and
select the section entitled Federal & Postal employees.
•There are dispensing limitations. These are the dispensing and quantity limitations. Prescription drugs will be
dispensed in the quantity determined by Us. In order for Prescription Drugs to be covered in excess of the specific
quantity limit, your physician must call Us before you fill the Prescription Order or Refill for a drug that exceeds the
specific quantity limit.
Dispensing limits are described below:
Retail Drugs
In general, the quantity of a Prescription Drug dispensed by a Retail Pharmacy for each Prescription Order or Refill is limited
to the lesser of:
•The amount determined by Us to be a 30-day supply
•The amount prescribed in the Prescription Order or Refill; or
•Depending on the form and packaging of the product, the following:
- 100 tablets/capsules, or
- 480 cc of oral liquids; or
- A single commercially prepackaged item (including but not limited to inhalers, topicals, and vials).
Mail Order Drugs
The quantity of a Prescription Drug dispensed by the Mail Order Pharmacy for one Prescription Order or Refill for a
Maintenance Drug is limited to the lesser of:
•The amount prescribed in the Prescription Order or Refill; or
53 2013 Coventry Health Care High and Standard Option Section 5(f)
High and Standard Option
•The amount determined by Us to be Medically Necessary; or
•The amount determined by Us to be a 90-day supply; or
•Depending on the form and packaging of the product, the following:
- 300 tablets/capsules, or
- 1,440 cc of oral liquids; or
- three (3) single commercially prepackaged items (including but not limited to inhalers, topicals, and vials).
The following Member payments shall apply:
1. High Option: One (1) copayment (i.e. $3 for Tier 1A (a list of specific generic medications)), $15 for Tier 1, $30 for Tier 2
(prescription drugs we have designated as Tier 2), $60 for Tier 3 (prescription drugs that are not otherwise designated as
Tier 1 or Tier 2, including brand name and generic prescription drugs that are not on our drug formulary) or the cost of the
prescription drug, whichever is less, is due each time a prescription is filled or refilled at a retail or specialty pharmacy.
Standard Option: One (1) copayment (i.e. $3 for Tier 1A (a list of specific generic medications)), $15 for Tier 1, $30 for
Tier 2 (prescription drugs we have designated as Tier 2), $60 for Tier 3 (prescription drugs that are not otherwise
designated as Tier 1or Tier 2, including brand name and generic prescription drugs that are not on our drug formulary) or
the cost of the prescription drug, whichever is less, is due each time a prescription is filled or refilled at a retail or specialty
pharmacy.
2. Formulary maintenance drugs obtained through a mail order pharmacy designated by the Health Plan may be dispensed
with two (2) copayments for a ninety - (90) day’s supply (i.e. High Option: $6 for Tier 1A (a list of specific generic
medications)), $30 copayment for Tier 1, $60 for Tier 2 (prescription drugs we have designated as Tier 2), $120 for Tier 3
(prescription drugs that are not otherwise designated as Tier 1 or Tier 2, including brand name and generic prescription
drugs that are not on our drug formulary). Standard Option: $6 for Tier 1A (a list of specific generic medications), $30
copayment for Tier 1, $60 for Tier 2 (prescription drugs we have designated as Tier 2), and $120 for Tier 3 (prescription
drugs that are not otherwise designated as Tier 1or Tier 2, including brand name and generic prescription drugs that are not
on our drug formulary). To order prescription drugs or refills please contact Medco’s Customer Service at
800-378-7040. This service is available 24 hours a day – 7 days a week.
3. Total member payments shall not exceed the price of the prescription drug. Copayments and Ancillary Charges do not
apply do the member’s Out-of-Pocket Maximum.
A generic equivalent will be dispensed if it is available. If the brand name prescription drug is dispensed and an equivalent
generic prescription drug is available, the member shall pay an “ancillary charge” in addition to the brand name copayment.
The ancillary charge will be due regardless of whether or not the prescribing physician indicates that the pharmacy is to
“Dispense as Written. ” The Ancillary Charge is the difference between the price of the brand name and generic.
Why use generic drugs? Generic drugs are lower-priced drugs that are the therapeutic equivalent to more expensive brand-
name drugs. They must contain the same active ingredients and must be equivalent in strength and dosage to the original
brand-name product. Generics cost less than the equivalent brand-name product. The U.S. Food and Drug Administration
sets quality standards for generic drugs to ensure that these drugs meet the same standards of quality and strength as brand-
name drugs.
You can save money by using generic drugs. However, you and your physician have the option to request a name brand if a
generic option is available. Using the most cost-effective medication saves money.
When you do have to file a claim? When you receive drugs from a plan pharmacy you do not have to file a claim. For a
covered out-of –area emergency, you will need to file a claim when you receive drugs from a non-plan pharmacy. To file a
pharmacy claim, call Medco at 800-378-7040.
54 2013 Coventry Health Care High and Standard Option Section 5(f)
High and Standard Option
Benefit Description You pay
Covered medications and supplies High Option Standard Option
We cover the following medications and supplied
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 syringesfor the
administration of covered medications
•Drugs for sexual dysfunction
Women's contraceptive drugs and devices Nothing Nothing
Not covered:
•
Compounded prescriptions whose only ingredients
do not require prescription
•
Legend drugs for which there is a non-prescription
equivalent such as vitamins, except legend prenatal
vitamins for pregnant/nursing females, liquid or
chewable legend pediatric vitamins for children
under age 13, and potassium supplements to
prevent/treat low potassium
•
Prescription drugs and supplies for cosmetic
purposes
•
Drugs to enhance athletic performance
•
Dietary supplements, appetite suppressants, and
other drugs used to treatment obesity or assist in
weight reduction
•
Drugs obtained at a non-Plan pharmacy; except for
out-of-area emergencies
•
Vitamins, nutrients and food supplements even if a
physician prescribes or administers them, except as
specified herein
•
Nonprescription medicines
•
Charges for special re-packaging of medications
prepared by the pharmacy such as “unit dose” or
“bubble pack”
•
Oral dental preparations, fluoride rinses, except
fluoride tablets or drops
•
Refill prescriptions resulting from loss or theft
All charges All charges
Covered medications and supplies - continued on next page
55 2013 Coventry Health Care High and Standard Option Section 5(f)
High and Standard Option
Benefit Description You pay
Covered medications and supplies (cont.) High Option Standard Option
Note: Over-the-counter and prescription drugs
approved by the FDA to treat tobacco dependence are
covered under the Tobacco cessation benefit and
require a written prescription by an approved
provider. (see Educational classes and Programs,
page 31 ).
All charges All charges
56 2013 Coventry Health Care High and Standard Option Section 5(f)
Section 5(g). Dental benefits
High and Standard Option
Important things you should keep in mind about these benefits:
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.
•If you are enrolled in a Federal Employees Dental Vision Insurance Program (FEDVIP) Dental Plan,
your FEHB Plan will be First Primary payor of any Benefit Payments and your FEDVIP Plan is
secondary to your FEHB Plan. See Section 9 Coordinating benefits with other coverage.
•Plan providers must provide or arrange your care.
•We cover hospitalization for dental procedures only when a non-dental physical impairment exists
which makes hospitalization necessary to safeguard the health of the patient. See Section 5(c) for
inpatient hospital benefits. We do not cover the dental procedure unless it is described below.
•Be sure to read Section 4,
Your costs for covered services,
for valuable information about how cost-
sharing works. Also read Section 10 about coordinating benefits with other coverage, including
with Medicare.
Accidental injury benefit High Option Standard Option
We cover restorative services and supplies necessary
to promptly repair (but not replace) sound natural
teeth. The need for these services must result from an
accidental injury.
$20 copayment to your primary
care physician
$40 copayment to a specialist
You pay nothing if services
received during an inpatient
admission
$20 copayment to your primary
care physician (No deductible)
$40 copayment to a specialist
(No deductible)
You pay nothing if services
received during an inpatient
admission
Dental benefits High Option Standard Option
We have no other dental benefits.
57 2013 Coventry Health Care High and Standard Option Section 5(g)
Section 5(h). Special features
Feature Description
Flexible benefits option High Option
Flexible benefits optionUnder the flexible benefits option, we determine the most effective way to
provide services.
• We may identify medically appropriate alternatives to regular contract
benefits as a less costly alternative. If we identify a less costly alternative,
we will ask you to sign an alternative benefits agreement that will include all
of the following terms in addition to other terms as necessary. Until you
sign and return the agreement, regular contract benefits will continue.
• Alternative benefits will be made available for a limited time period and are
subject to our ongoing review. You must cooperate with the review process.
• By approving an alternative benefit, we do not guarantee you will get it in
the future.
• The decision to offer an alternative benefit is solely ours, and except as
expressly provided in the agreement, we may withdraw it at any time and
resume regular contract benefits.
• If you sign the agreement, we will provide the agreed-upon alternative
benefits for the stated time period (unless circumstances change). You may
request an extension of the time period, but regular contract benefits will
resume if we do not approve your request.
Our decision to offer or withdraw alternative benefits is not subject to OPM
review under the disputed claims process. However, if at the time we make a
decision regarding alternative benefits, we also decide that regular contract
benefits are not payable, then you may dispute our regular contract benefits
decision under the OPM disputed claim process (see Section 8).
Wellness ProgramsCoventry Health Care offers an on-line wellness program called Wellbeing.
Wellbeing is a free service available only to Coventry Health Care members.
This on-line tool is available through our website, www.chcde.com/wellbeing.
This program allows Coventry members to utilize the MyEPHIT tool to
develop a customized exercise, nutrition or personal improvement program
with the assistance of on-line fitness experts. This online Personal Health
Improvement Training program is designed to enhance your overall
Wellbeing. Through Wellbeing, you can: • Customize a daily fitness routine,
including on-line demonstrations of specific exercises. • Personalize a nutrition
plan, including receiving a meal planner with menus and shopping lists. •
Download materials on life skills management, and family activity planning. •
Communicate on-line with a Certified personal trainer, registered dieticians,
and psychologists. • Download recipes for healthy menus. • Discover online
family programs through KidPHIT and TeenPHIT, which allows your children
to become motiviated for a healthier lifestyle. • Earn REWARDS! Through the
Wellbeing program, just by signing on every month, you will be entered into a
monthly drawing for prizes such as mountain bikes, DVD players, and other
fitness related prizes!
• Earn points towards the purchase of discounted fitness items. Through the
online My EPHIT Mall, members can use the points they earn on the website
to purchase items such as Yoga Mats, vitamins, or workout videos.
58 2013 Coventry Health Care High and Standard Option Section 5(h)
Feature Description
Travel benefit/services overseas High Option
Travel benefit/services overseasYour Benefit Plan does not include out-of-network benefits, however; if you
are out of our service area and in need of Urgent or Emergent Care, please call
800-639-9154 for a First Health network provider in your area.
59 2013 Coventry Health Care High and Standard Option Section 5(h)
High Deductible Health Plan Benefits
HDHP Option
See page 8 for how our benefits changed this year and page 117 for a benefits summary.
Section 5. High Deductible Health Plan Benefits Overview ......................................................................................................62
Section 5. Savings – HSAs and HRAs ........................................................................................................................................65
Section 5. Preventive care ...........................................................................................................................................................71
Preventive care, adult ........................................................................................................................................................71
Preventive care, children ...................................................................................................................................................72
Section 5. Traditional medical coverage subject to the deductible .............................................................................................73
Deductible before Traditional medical coverage begins ...................................................................................................73
Section 5(a). Medical services and supplies provided by physicians and other health care professionals .................................74
Diagnostic and treatment services .....................................................................................................................................74
Lab, X-ray and other diagnostic tests ................................................................................................................................74
Maternity care ...................................................................................................................................................................75
Family planning ................................................................................................................................................................75
Infertility services .............................................................................................................................................................76
Allergy care .......................................................................................................................................................................76
Treatment therapies ...........................................................................................................................................................77
Physical and occupational therapies .................................................................................................................................77
Speech therapy ..................................................................................................................................................................77
Hearing services (testing, treatment, and supplies) ...........................................................................................................78
Vision services (testing, treatment, and supplies) .............................................................................................................78
Foot care ............................................................................................................................................................................78
Orthopedic and prosthetic devices ....................................................................................................................................79
Durable medical equipment (DME) ..................................................................................................................................79
Home health services ........................................................................................................................................................80
Chiropractic .......................................................................................................................................................................80
Alternative treatments .......................................................................................................................................................80
Educational classes and programs .....................................................................................................................................80
Medical Clinical Trial .......................................................................................................................................................81
Section 5(b). Surgical and anesthesia services provided by physicians and other health care professionals .............................82
Surgical procedures ...........................................................................................................................................................82
Reconstructive surgery ......................................................................................................................................................83
Oral and maxillofacial surgery ..........................................................................................................................................84
Organ/tissue transplants ....................................................................................................................................................84
Anesthesia .........................................................................................................................................................................88
Section 5(c). Services provided by a hospital or other facility, and ambulance services ...........................................................89
Inpatient hospital ...............................................................................................................................................................89
Outpatient hospital or ambulatory surgical center ............................................................................................................90
Extended care benefits/Skilled nursing care facility benefits ...........................................................................................90
Hospice care ......................................................................................................................................................................90
Ambulance ........................................................................................................................................................................91
Section 5(d). Emergency services/accidents ...............................................................................................................................92
Emergency within our service area ...................................................................................................................................93
Emergency outside our service area ..................................................................................................................................93
Ambulance ........................................................................................................................................................................93
Section 5(e). Mental health and substance abuse benefits ..........................................................................................................94
Professional services .........................................................................................................................................................94
60 2013 Coventry Health Care HDHP Section 5
HDHP Option
Diagnostics ........................................................................................................................................................................95
Inpatient hospital or other covered facility .......................................................................................................................95
Outpatient hospital or other covered facility .....................................................................................................................95
Section 5(f). Prescription drug benefits ......................................................................................................................................96
Covered medications and supplies ....................................................................................................................................98
Section 5(g). Dental benefits .....................................................................................................................................................100
Accidental injury benefit .................................................................................................................................................100
Dental benefits ................................................................................................................................................................100
Section 5(h). Special features ....................................................................................................................................................101
Flexible benefits option ...................................................................................................................................................101
Wellness Programs ..........................................................................................................................................................101
Travel benefit/services overseas .....................................................................................................................................102
Section 5(i). Health education resources and account management tools ................................................................................103
Health education resources .............................................................................................................................................103
Account management tools .............................................................................................................................................103
Consumer choice information .........................................................................................................................................104
Care support ....................................................................................................................................................................104
Summary of benefits for the HDHP of Coventry Health Care - 2013 ......................................................................................129
61 2013 Coventry Health Care HDHP Section 5
Section 5. High Deductible Health Plan Benefits Overview
HDHP Option
This Plan offers a High Deductible Health Plan (HDHP). The HDHP benefit package is described in this section.
Make sure that you review the benefits that are available under the benefit product in which you are enrolled.
HDHP Section 5, which describes the HDHP benefits, is divided into subsections. Please read
Important things you should
keep in mind about these benefits
at the beginning of each subsection. Also read the General Exclusions in Section 6; they
apply to benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about HDHP
benefits, contact us at 800-833-7423 or at our Web site at www.chcde.com.
Our HDHP option provides comprehensive coverage for high-cost medical events and a tax-advantaged way to help you
build savings for future medical expenses. The Plan gives you greater control over how you use your health care benefits.
When you enroll in this HDHP, we establish either a Health Savings Account (HSA) or a Health Reimbursement
Arrangement (HRA) for you. We automatically pass through a portion of the total health Plan premium to your HSA or
credit an equal amount to your HRA based upon your eligibility. Your full annual HRA credit will be available on your
effective date of enrollment.
With this Plan, preventive care is covered in full. As you receive other non-preventive medical care, you must meet the
Plan’s deductible before we pay benefits according to the benefits described on page 65. You can choose to use funds
available in your HSA to make payments toward the deductible or you can pay toward your deductible entirely out-of-pocket,
allowing your savings to continue to grow.
This HDHP includes five key components: preventive care; traditional medical coverage health care that is subject to the
deductible; savings; catastrophic protection for out-of-pocket expenses; and health education resources and account
management tools.
The Plan covers preventive care services, such as periodic health evaluations (e.g., annual
physicals), screening services (e.g., mammograms), routine prenatal and well-child care,
child and adult immunizations, tobacco cessation programs, obesity weight loss programs,
disease management and wellness programs. Preventive services are covered at 100% if
you use a network provider and the services are described in Section 5
Preventive care
.
You do not have to meet the deductible before using these services.
• Preventive care
After you have paid the Plan’s deductible, we pay benefits under traditional medical
coverage described in Section 5. The Plan typically pays 100% of allowable charges for
in-network and 70% for out-of-network care.
Covered services include:
• Medical services and supplies provided by physicians and other health care
professionals
• Surgical and anesthesia services provided by physicians and other health care
professionals
• Hospital services; other facility or ambulance services
• Emergency services/accidents
• Mental health and substance abuse benefits
• Prescription drug benefits
• Dental benefits.
• Traditional medical
coverage
Health Savings Accounts or Health Reimbursement Arrangements provide a means to
help you pay out-of-pocket expenses (see page 57 for more details).
• Savings
62 2013 Coventry Health Care HDHP Section 5 Overview
HDHP Option
By law, HSAs are available to members who are not enrolled in Medicare, cannot be
claimed as a dependent on someone else’s tax return, have not received VA or Indian
Health Services (IHS) benefits within the last three months or do not have other health
insurance coverage other than another high deductible health plan. In 2013, for each
month you are eligible for an HSA premium pass through, we will contribute to your HSA
$41.67 per month for a Self Only enrollment or $83.34 per month for a Self and Family
enrollment. In addition to our monthly contribution, you have the option to make
additional tax-free contributions to your HSA, so long as total contributions do not exceed
the limit established by law, which is $3,250 for an individual plan and $6,450 for a
family. See maximum contribution information on page 60. You can use funds in your
HSA to help pay your health plan deductible. You own your HSA, so the funds can go
with you if you change plans or employment.
Federal tax tip: There are tax advantages to fully funding your HSA as quickly as
possible. Your HSA contribution payments are fully deductible on your Federal tax
return. By fully funding your HSA early in the year, you have the flexibility of paying
medical expenses from tax-free HSA dollars or after tax out-of-pocket dollars. If you
don’t deplete your HSA and you allow the contributions and the tax-free interest to
accumulate, your HSA grows more quickly for future expenses.
HSA features include:
• Your HSA is administered by Coventry Consumer Advantage
• Your contributions to the HSA are tax deductible
• You may establish pre-tax HSA deductions from your paycheck to fund your HSA up
to IRS limits using the same method that you use to establish other deductions (i.e.,
Employee Express, MyPay, etc.)
• Your HSA earns tax-free interest
• You can make tax-free withdrawals for qualified medical expenses for you, your
spouse and dependents (see IRS publication 502 for a complete list of eligible
expenses)
• Your unused HSA funds and interest accumulate from year to year
• It’s portable - the HSA is owned by you and is yours to keep, even when you leave
Federal employment or retire
• When you need it, funds up to the actual HSA balance are available.
Important consideration if you want to participate in a Health Care Flexible
Spending Account (HCFSA): If you are enrolled in this HDHP with a Health Savings
Account (HSA), and start or become covered by a HCFSA health care flexible spending
account (such as FSAFEDS offers – see Section 11), this HDHP cannot continue to
contribute to your HSA. Similarly, you cannot contribute to an HSA if your spouse
enrolls in an HCFSA. Instead, when you inform us of your coverage in an HCFSA, we
will establish an HRA for you.
• Health Savings
Accounts (HSA)
If you aren’t eligible for an HSA, for example you are enrolled in Medicare or have
another health plan, we will administer and provide an HRA instead. You must notify us
that you are ineligible for an HSA.
In 2013, we will give you an HRA credit of $500 per year for a Self Only enrollment and
$1,000 per year for a Self and Family enrollment. You can use funds in your HRA to help
pay your health plan deductible and/or for certain expenses that don’t count toward the
deductible.
HRA features include:
• For our HDHP option, we administer the HRA through Coventry Consumer Choice.
• Health
Reimbursement
Arrangements (HRA)
63 2013 Coventry Health Care HDHP Section 5 Overview
HDHP Option
• Entire HRA credit (prorated from your effective date to the end of the plan year) is
available from your effective date of enrollment
• Tax-free credit can be used to pay for qualified medical expenses for you and any
individuals covered by this HDHP
• Unused credits carryover from year to year
• HRA credit does not earn interest
• HRA credit is forfeited if you leave Federal employment or switch health insurance
plans.
• An HRA does not affect your ability to participate in an FSAFEDS Health Care
Flexible Spending Account (HCFSA). However, you must meet FSAFEDS eligibility
requirements.
When you use network providers, your annual maximum for out-of-pocket expenses
(deductibles, coinsurance and copayments) for covered services is limited to $ 4,000 per
person or $ 8,000 per family enrollment. However, certain expenses do not count toward
your out-of-pocket maximum and you must continue to pay these expenses once you
reach your out-of-pocket maximum (such as expenses in excess of the Plan’s allowable
amount or benefit maximum). Refer to Section 4 Your catastrophic protection out-of-
pocket maximum and HDHP Section 5
Traditional medical coverage subject to the
deductible
for more details.
• Catastrophic
protection for out-of-
pocket expenses
HDHP Section 5(i) describes the health education resources and account management
tools available to you to help you manage your health care and your health care dollars.
• Health education
resources and account
management tools
64 2013 Coventry Health Care HDHP Section 5 Overview
Section 5. Savings – HSAs and HRAs
HDHP
Health Savings Account (HSA)Health Reimbursement Arrangement
(HRA)
Provided when you are
ineligible for an HSA
Feature
Comparison
The Plan will establish an HSA for you with
Coventry Consumer Advantage, this HDHP’s
fiduciary (an administrator, trustee or
custodian as defined by Federal tax code and
approved by IRS.)
Name: Coventry Consumer Advantage
Street Address: P.O. Box 7758
City, State ZIP Code: London, KY 40742
Phone: 800-722-1758
OR
www.chcde.com
The Plan will establish and HRA for you with
Coventry Consumer Advantage.
HRA Administrator: Coventry Consumer
Advantage
Fiduciary: There is no fiduciary for HRA's.
Street Address: P.O. Box 7758
City, State ZIP Code: London, KY 40742
Administrator
Order New Debit Card: $5.00
Debit Card Reissue: $10.00
Close Account: $30.00
Overdraft/Insufficient Funds: $50.00
Stop payment requests per item: $30.00
Request copy of debit card transaction
merchant receipt: $30.00
None. Fees
You must:
• enroll in this HDHP
• have no other health insurance coverage
(does not apply to specific injury,
accident, disability, dental, vision or long-
term care coverage)
• not be enrolled in Medicare
• not be claimed as a dependent on someone
else’s tax return
• not have received VA benefits in the last
three months
• complete and return all banking
paperwork
You must enroll in this HDHP.
Eligibility is determined on the first day of the
month following your effective day of
enrollment and will be prorated for lenth of
enrollment.
Eligibility
If you are eligible for HSA contributions, a
portion of your monthly health plan premium
is deposited to your HSA each month.
Premium pass through contributions are based
on the effective date of your enrollment in the
HDHP.
Eligibility for the annual credit will be
determined on the first day of the month and
will be prorated for length of enrollment. The
entire amount of your HRA will be available
to you upon your enrollment.
Funding
65 2013 Coventry Health Care HDHP Section 5 Savings – HSAs and HRAs
HDHP
For 2013, a monthly premium pass through of
$41.67 will be made by the HDHP directly
into your HSA each month.
For 2013, your HRA annual credit is $500
(prorated for mid year enrollment).
• Self Only
enrollment
For 2013, a monthly premium pass through of
$83.34 will be made by the HDHP directly
into your HSA each month.
For 2013, your HRA annual credit is $1,000
(prorated for mid year enrollment).
• Self and Family
enrollment
The maximum that can be contributed to your
HSA is an annual combination of HDHP
premium pass through and enrollee
contribution funds, which when combined, do
not exceed the maximum contribution amount
set by the IRS of $3,250 for an individual and
$6,450 for a family.
If you enroll during Open Season, you are
eligible to fund your account up to the
maximum contribution limit set by the IRS.
To determine the amount you may contribute,
subtract the amount the Plan will contribute to
your account for the year from the maximum
allowable contribution.
You are eligible to contribute up to the IRS
limit for partial year coverage as long as you
maintain your HDHP enrollment for 12
months, following the last month of the year
of your first year of eligibility. To determine
the amount you may contibute, take the IRS
limit and subtract the amount the Plan will
contribute to your account for the year.
If you do not maintain your HDHP enrollment
for 12 months, the maximum contribution
amount is reduced by 1/12 for any month you
were ineligible to contribute to an HSA. If
you exceed the maximum contribution
amount, a portion of you tax reduction is lost
and a 10% pendalty is imposed. There is an
exception for death or disability.
You may rollover funds you have in other
HSAs to this HDHP HSA (rollover funds do
not affect your annual maximum contribution
under this HDHP).
HSAs earn tax-free interest (does not affect
your annual maximum contribution).
Catch-up contribution discussed on page 58.
The full HRA credit will be available, subject
to proration, on the effective date of
enrollment. The HRA does not earn interest.
Contributions/
credits
You may make an annual maximum
contribution of $2,750.
You cannot contribute to the HRA. • Self Only
enrollment
You may make an annual maximum
contribution of $5,450.
You cannot contribute to the HRA • Self and Family
enrollment
You can access your HSA by the following
methods:
Access funds
66 2013 Coventry Health Care HDHP Section 5 Savings – HSAs and HRAs
HDHP
• Debit card
• Withdrawal form
• Checks
For qualified medical expenses under your
HDHP, you will be automatically reimbursed
when claims are submitted through the HDHP.
For expenses not covered by the HDHP, such
as orthodontia, a reimbursement form will be
sent to you upon your request.
You can pay the out-of-pocket expenses for
yourself, your spouse or your dependents
(even if they are not covered by the HDHP)
from the funds available in your HSA.
See IRS Publication 502 for a list of eligible
medical expenses.
You can pay the out-of-pocket expenses for
qualified medical expenses for individuals
covered under the HDHP.
Non-reimbursed qualified medical expenses
are allowable if they occur after the effective
date of your enrollment in this Plan.
See
Availability of funds
below for
information on when funds are also available
in the HRA.
See IRS Publication 502 for a list of eligible
medical expenses. Physicians prescribed over-
the-counter drugs and Medicare premiums are
also reimbursable. Most other types of
medical insurance premiums are not
reimbursable.
Distributions/
withdrawals
• Medical
If you are under age 65, withdrawal of funds
for non-medical expenses will create a 20%
income tax penalty in addition to any other
income taxes you may owe on the withdrawn
funds.
When you turn age 65, distributions can be
used for any reason without being subject to
the 20% penalty, however they will be subject
to ordinary income tax.
Not applicable – distributions will not be
made for anything other than non-reimbursed
qualified medical expenses.
• Non-medical
Funds are not available for withdrawal until
all the following steps are completed:
• Your enrollment in this HDHP is effective
(effective date is determined by your
agency in accord with the event permitting
the enrollment change).
• The HDHP receives record of your
enrollment and initially establishes your
HSA account with the fiduciary by
providing information it must furnish and
by contributing the minimum amount
required to establish an HSA.
• The fiduciary sends you HSA paperwork
for you to complete and the fiduciary
receives the completed paperwork back
from you.
The entire amount of your HRA will be
available to you upon your enrollment in the
HDHP.
Availability of
funds
FEHB enrollee HDHP Account owner
You can take this account with you when you
change plans, separate or retire.
Portable
67 2013 Coventry Health Care HDHP Section 5 Savings – HSAs and HRAs
HDHP
If you do not enroll in another HDHP, you can
no longer contribute to your HSA. See page
55 for HSA eligibility.
If you retire and remain in this HDHP, you
may continue to use and accumulate credits in
your HRA.
If you terminate employment or change health
plans, only eligible expenses incurred while
covered under the HDHP will be eligible for
reimbursement subject to timely filing
requirements. Unused funds are forfeited.
Yes, accumulates without a maximum cap. Yes, accumulates without a maximum cap. Annual rollover
68 2013 Coventry Health Care HDHP Section 5 Savings – HSAs and HRAs
HDHP
If you have an HSA
All contributions are aggregated and cannot exceed the maximum contribution amount set
by the IRS. You may contribute your own money to your account through payroll
deductions, or you may make lump sum contributions at any time, in any amount not to
exceed an annual maximum limit. If you contribute, you can claim the total amount you
contributed for the year as a tax deduction when you file your income taxes. Your own
HSA contributions are either tax-deductible or pre-tax (if made by payroll deduction).
You receive tax advantages in any case. To determine the amount you may contribute,
subtract the amount the plan will contribute to your account for the year from the
maximum contribution set by the IRS. You have until April 15 of the following year to
make HSA contributions for the current year.
If you newly enroll in an HDHP during Open Season and your effective date is after
January 1st or you otherwise have partial year coverage, you are eligible to fund your
account up to the maximum contribution limit set by the IRS as long as you maintain your
HDHP enrollment for 12 months following the last month of the year of your first year of
eligibility. If you do not meet this requirement, a portion of your tax reduction is lost and
a 10% penalty is imposed. There is an exception for death or disability.
• Contributions
If you are age 55 or older, the IRS permits you to make additional “catch-up”
contributions to your HSA. The allowable catch-up contribution is $1,000. Contributions
must stop once an individual is enrolled in Medicare. Additional details are available on
the U.S. Department of Treasury Web site at www.ustreas.gov/offices/public-affairs/hsa/.
• Catch-up
contributions
If you do not have a named beneficiary, if you are married, it becomes your spouse’s
HSA; otherwise, it becomes part of your taxable estate.
• If you die
You can pay for “qualified medical expenses,” as defined by IRS Code 213(d). These
expenses include, but are not limited to, medical plan deductibles, diagnostic services
covered by your plan, long-term care premiums, health insurance premiums if you are
receiving Federal unemployment compensation, physician prescribed over-the-counter
drugs, LASIK surgery, and some nursing services.
When you enroll in Medicare, you can use the account to pay Medicare premiums or to
purchase health insurance other than a Medigap policy. You may not, however, continue
to make contributions to your HSA once you are enrolled in Medicare.
For a detailed list of IRS-allowable expenses, request a copy of IRS Publication 502 by
calling 1-800-829-3676, or visit the IRS Web site at www.irs.gov and click on “Forms and
Publications.” Note: Although physician prescribed over-the-counter drugs are not listed
in the publication, they are reimbursable from your HSA. Also, insurance premiums are
reimbursable under limited circumstances.
• Qualified expenses
You may withdraw money from your HSA for items other than qualified health expenses,
but it will be subject to income tax and if you are under 65 years old, an additional 20%
penalty tax on the amount withdrawn.
• Non-qualified
expenses
You will receive a periodic statement that shows the “premium pass through”,
withdrawals, and interest earned on your account. In addition, you will receive an
Explanation of Payment statement when you withdraw money from your HSA.
• Tracking your HSA
balance
You can request reimbursement in any amount. • Minimum
reimbursements from
your HSA
69 2013 Coventry Health Care HDHP Section 5 Savings – HSAs and HRA
HDHP
If you have an HRA
If you don’t qualify for an HSA when you enroll in this HDHP, or later become ineligible
for an HSA, we will establish an HRA for you. If you are enrolled in Medicare, you are
ineligible for an HSA and we will establish an HRA for you. You must tell us if you
become ineligible to contribute to an HSA.
• Why an HRA is
established
Please review the chart on page 60 which details the differences between an HRA and an
HSA. The major differences are:
• you cannot make contributions to an HRA
• funds are forfeited if you leave the HDHP
• an HRA does not earn interest
• HRAs can only pay for qualified medical expenses, such as deductibles, copayments,
and coinsurance expenses, for individuals covered by the HDHP. FEHB law does not
permit qualified medical expenses to include services, drugs, or supplies related to
abortions, except when the life of the mother would be endangered if the fetus were
carried to term, or when the pregnancy is the result of an act of rape or incest.
• How an HRA differs
70 2013 Coventry Health Care
Section 5. Preventive care
HDHP Option
Important things you should keep in mind about these benefits:
•Preventive care services listed in this Section are covered in full and are not subject to the deductible
if you use network providers.
•You must use providers that are part of our network.
•For all other covered expenses, please see Section 5 –
Traditional medical coverage subject to the
deductible
.
Benefit Description You pay
Preventive care, adult
Routine screenings, such as:
• Bloodtests
• Urinalysis
• Total Blood Cholesterol
• Routine Prostate Specific Antigen (PSA) test —one annually for men
age 50 and older
• Colorectal Cancer Screening, including:
- Fecal occult blood testyearly starting at age 50
- Sigmoidoscopy screening —every five years starting at age 50
- Double contrast barium enema —every five years starting at age 50
- Colonoscopy screening —every 10 years starting at age 50
- Routine annual digital rectal exam (DRE) for men age 40 and older
In Network: You pay nothing and do not have
to meet the deductible before using these
services. They are covered with no member
cost share.
Out of Network: Services are subject to the
deductible and then you must pay 30% of our
allowance.
Not covered:
•
Physical exams required for obtaining or continuing employment or
insurance, attending schools or camp, or travel.
•
Immunizations, boosters, and medications for travel.
All charges
•Well woman -one annually; including, but not limited to:
-Routine pap test
-Human papillomavirus testing for women age 30 and up once every
three years
-Counseling for sexually transmitted infections on an annual basis.
-Counseling and screening for human immune-deficiency virus on an
annual basis.
-Contraceptive methods and counseling on an annual basis-Screening
and counseling for interpersonal and domestic violence
In Network: You pay nothing and do not have
to meet the deductible before using these
services. They are covered with no member
cost share.
Out of Network: Services are subject to the
deductible and then you must pay 30% of our
allowance.
71 2013 Coventry Health Care HDHP Section 5 Preventive care
HDHP Option
Benefit Description You pay
Preventive care, children
• Professional services, such as:
• Well-child care charges for routine examinations, immunizations and
care (up to age 22)
• Childhood immunizations recommended by the American Academy
of Pediatrics
• Examinations, such as:
• Eye exam through age 17 to determine the need for vision correction
• Hearing exams through age 17 to determine the need for hearing
correction
• Examinations done on the day of immunizations (up to age 22)
In Network: You pay nothing and do not have
to meet the deductible before using these
services. They are covered with no member
cost share.
Out of Network: Services are subject to the
deductible and then you must pay 30% of our
allowance.
72 2013 Coventry Health Care HDHP Section 5 Preventive care
Section 5. Traditional medical coverage subject to the deductible
HDHP
Important things you should keep in mind about these benefits:
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.
•In-network preventive care is covered at 100% of allowable charges (see page 60) up to the annual
limit and is not subject to the calendar year deductible.
•The deductible is $2,000, per person or $4,000, per family enrollment. The family deductible can be
satisfied by one or more family members. The deductible applies to almost all benefits under
Traditional medical coverage. You must pay your deductible before your Traditional medical
coverage may begin.
•Under Traditional medical coverage, you are responsible for your coinsurance and copayments for
covered expenses.
•When you use network providers, you are protected by an annual catastrophic maximum on out-of-
pocket expenses for covered services. After your coinsurance, copayments and deductibles total
$4,000 per person or $8,000 per family enrollment in any calendar year, you do not have to pay any
more for covered services from network providers. However, certain expenses do not count toward
your out-of-pocket maximum and you must continue to pay these expenses once you reach your out-
of-pocket maximum (such as expenses in excess of the Plan’s benefit maximum, or if you use out-
of-network providers, amounts in excess of the Plan allowance).
•In-network benefits apply only when you use a network provider. When a network provider is not
available, out-of-network benefits apply and are covered at 30% after the deductible has been met.
•Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-
sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with
Medicare.
Benefit Description You pay
Deductible before Traditional medical coverage begins
The deductible applies to almost all benefits in this Section. In the You
pay column, we say “No deductible” when it does not apply. When you
receive covered services from network providers, you are responsible for
paying the allowable charges until you meet the deductible.
100% of allowable charges until you meet the
deductible of $2,000 per person or $4,000 per
family enrollment
After you meet the deductible, we pay the allowable charge (less your
coinsurance or copayment) until you meet the annual catastrophic out-
of-pocket maximum.
In-network: After you meet the deductible, you
pay the indicated coinsurance or copayments
for covered services. You may choose to pay
the coinsurance and copayments from your
HSA or HRA, or you can pay for them out-of-
pocket.
Out-of-network: After you meet the deductible,
you pay the 30% coinsurance based on our
Plan allowance and any difference between our
allowance and the billed amount.
73 2013 Coventry Health Care HDHP Section 5 Traditional Medical Coverage
Section 5(a). Medical services and supplies
provided by physicians and other health care professionals
HDHP Option
Important things you should keep in mind about these benefits:
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.
•Plan physicians must provide or arrange your care.
•The deductible is $2,000 for Self Only enrollment and $4,000 for Self and Family enrollment each
calendar year. The Self and Family deductible can be satisfied by one or more family members.
The deductible applies to all benefits in this Section unless we indicate differently.
•After you have satisfied your deductible, coverage begins for traditional medical services.
•Under your Traditional medical coverage, you will be responsible for your coinsurance amounts or
copayments for eligible medical expenses and prescriptions.
•Be sure to read Section 4,
Your costs for covered services
, for valuable information about how cost-
sharing works. Also read Section 9 about coordinating benefits with other coverage, including with
Medicare.
Benefit Description You pay
Diagnostic and treatment services
Professional servicesof physician
• In physician's office
• In an urgent care center
• During a hospital stay
• In a skilled nursing facility
• Office medical consultations
• Second surgical opinion
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible
Lab, X-ray and other diagnostic tests
Tests, such as:
• Blood tests
• Urinalysis
• Non-routine Pap tests
• Pathology
• X-rays
• Non-routine mammograms
• CAT Scans/MRI
• Ultrasound
• Electrocardiogram and EEG
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible
74 2013 Coventry Health Care HDHP Section 5(a)
HDHP Option
Benefit Description You pay
Maternity care
Complete maternity (obstetrical) care, such as:
• Prenatal care
• Screening for gestational diabetes for pregnant women between 24-48
weeks gestation or first prenatal visit for women at a high risk.
• Delivery
• Postnatal care
• Breastfeeding support, supplies and counseling for each birth.
Note: Here are some things to keep in mind:
• You do not need to pre-certify your normal delivery; see below for
other circumstances, such as extended stays for you or your baby.
• You may remain in the hospital up to 48 hours after a regular delivery
and 96 hours after a cesarean delivery. We will extend your inpatient
stay if medically necessary, however you will need to get
preauthorization for extended days.
• For a mother and newborn child who have a Hospital stay of less than
48 hours for vaginal delivery or 96 hours for cesarean section,
benefits are provided for one home visit to occur within 24 hours after
discharge and an additional home visit if prescribed by the attending
provider.
• For a mother and newborn child who remain in the Hospital for at
least 48 or 96 hours of inpatient hospitalization, we shall provide
coverage for a home visit if prescribed by the attending provider.
• 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 for the first 31
days after birth. An enrollment form must be completed to cover the
infant under a Self and Family enrollment after the 31 days if you do
not already have Self and Family coverage
.
Surgical benefits, not
maternity benefits, apply to circumcision.
• If a mother is required to remain hospitalized after childbirth for
medical reasons and the mother requests that the newborn remain in
the Hospital, we shall provide as part of the hospitalization services,
payment for the cost of additional hospitalization for the newborn for
up to 4 days.
• We pay hospitalization and surgeon services for non-maternity care
the same as for illness and injury.
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible
Family planning
Contraceptive counseling on an annual basis Nothing
A range of voluntary family planning services, limited to:
• Voluntary sterilization (See Surgical procedures Section 5 (b))
• Surgically implanted contraceptive s
• Injectable contraceptive drugs (such as Depo provera)
• Intrauterine devices (IUDs)
• Diaphragms
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible
Family planning - continued on next page
75 2013 Coventry Health Care HDHP Section 5(a)
HDHP Option
Benefit Description You pay
Family planning (cont.)
Note: We cover oral contraceptives under the prescription drug benefit. In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible
Not covered:
•
Reversal of voluntary surgical sterilization
•
Genetic counseling.
•
Surrogate motherhood services and supplies, including, but not
limited to, all services and supplies relating to the conception and
pregnancy of a Member acting as a surrogate mother
All charges
Infertility services
Diagnosis and treatment of infertility such as:
• Artificial insemination:
- intravaginal insemination (IVI)
- intracervical insemination (ICI)
- intrauterine insemination (IUI)
• Fertility drugs
Note: We cover injectible fertility drugs under medical benefits and oral
fertility drugs under the prescription drug benefit.
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
Not covered:
•
Assisted reproductive technology (ART) procedures, such as:
-
in vitro fertilization
-
embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote
intra-fallopian transfer (ZIFT)
•
Services and supplies related to ART procedures
•
Cost of donor sperm
•
Cost of donor egg.
All charges
Allergy care
• Testing and treatment
• Allergy injections
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
Allergy serum In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
76 2013 Coventry Health Care HDHP Section 5(a)
HDHP Option
Benefit Description You pay
Treatment therapies
• 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 xx.
• Respiratory and inhalation therapy
• Dialysis – hemodialysis and peritoneal dialysis
• Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy
• Growth hormone therapy (GHT)
Note: Growth hormone is covered under the prescription drug benefit.
Note: – We only cover GHT when we preauthorize the treatment. We
will ask you to submit information that establishes that the GHT is
medically necessary. Ask us to authorize GHT before you begin
treatment. We will only cover GHT services and related services and
supplies the we determine are medically necessary. See
Other Services
under You need prior Plan approval for certain services in Section 3.
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
Physical and occupational therapies
60 visits for the services of each of the following:
• qualified physical therapists and
• occupational therapists
Note: We only cover therapy to restore bodily function when there has
been a total or partial loss of bodily function due to illness or injury.
• Cardiac rehabilitation following a heart transplant, bypass surgery or a
myocardial infarction is provided for up to 60 sessions.
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
Not covered:
•
Long-term rehabilitative therapy
•
Exercise programs
All charges
Speech therapy
60 visits per condition per calendar year In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
Habilitative services
Habilitative services for the treatment of a child with congenital or
genetic birth defects to enhance the child’s ability to function are
covered for children under the age of 19 if preauthorized by us. Services
include
• occupational,
• physical
• speech therapy
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
Habilitative services - continued on next page
77 2013 Coventry Health Care HDHP Section 5(a)
HDHP Option
Benefit Description You pay
Habilitative services (cont.)
Not covered:
Habilitative services delivered through early intervention or school
services
All charges
Hearing services (testing, treatment, and supplies)
• First hearing aid and testing only when necessitated by accidental
injury.
• Hearing exams for children through age 17, as shown in
Preventive
care, children;
• Hearing aids for minor children up to a maximum Plan benefit of
$1,400 per hearing aid per ear every 36 months when prescribed by a
licensed audiologist.
• Hearing aids for adults up to a maximum Plan benefit of $500 per
hearing aid per ear every 5 years when prescribed by a licensed
audiologist.
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
Not covered:
•
Hearing services that are not shown as covered.
All charges
Vision services (testing, treatment, and supplies)
• One pair of eyeglasses or contact lenses to correct an impairment
directly caused by accidental ocular injury or intraocular surgery
(such as for cataracts)
• Eye exam to determine the need for vision correction for children
through age 17 (see Preventive care, children)
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
Not covered:
•
Eyeglasses or contact lenses, except as shown above
•
Eye exercises and orthoptics
•
Radial keratotomy and other refractive surgery
•
Annual Refraction
All charges
Foot care
Routine foot care when you are under active treatment for a metabolic or
peripheral vascular disease, such as diabetes.
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
Not covered:
•
Cutting, trimming or removal of corns, calluses, or the free edge of
toenails, and similar routine treatment of conditions of the foot, except
as stated above
•
Treatment of weak, strained or flat feet or bunions or spurs; and of
any instability, imbalance or subluxation of the foot (unless the
treatment is by open cutting surgery)
All charges
78 2013 Coventry Health Care HDHP Section 5(a)
HDHP Option
Benefit Description You pay
Orthopedic and prosthetic devices
• Artificial limbs and eyes
• Stump hose
• Externally worn breast prostheses and surgical bras, including
necessary replacements following a mastectomy
• Hearing aids and testing to fit them (for details refer to Hearing
Services page 72)
• Internal prosthetic devices, such as artificial joints, pacemakers,
cochlear implants, 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 and anesthesia
services. 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.
• Corrective orthopedic appliances for non-dental treatment of
temporomandibular joint (TMJ) pain dysfunction syndrome.
Prosthetic replacements are provided when preauthorized.
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
Not covered:
•
Orthopedic and corrective shoes
, a
rch supports, f oot orthotics
,
heel
pads and heel cups
•
Lumbosacral supports
•
Corsets, trusses, elastic stockings, suppor t hose, and other supportive
devices
•
Braces and supports needed for athletic participation or employment
All charges
Durable medical equipment (DME)
Rental or purchase, at our option, including repair and adjustment, of
durable medical equipment prescribed by your Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:
• Hospital beds;
• Wheelchairs;
• Crutches;
• Walkers;
• Blood glucose monitors; and
• Insulin pumps.
Note: Call us at 800-833-7423 as soon as your Plan physician prescribes
this equipment. We will arrange with a health care provider to rent or
sell you durable medical equipment at discounted rates and will tell you
more about this service when you call.
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
Not covered:
Motorized wheelchair, wigs (except as noted above), and upgrades to
equipment.
All charges
79 2013 Coventry Health Care HDHP Section 5(a)
HDHP Option
Benefit Description You pay
Home health services
• Home health care 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.
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
Not covered:
•
Nursing care requested by, or for the convenience of, the patient or the
patient’s family;
•
Home care primarily for personal assistance that does not include a
medical component and is not diagnostic, therapeutic, or
rehabilitative.
All charges
Chiropractic
• Limited to 20 visits per calendar year
• Manipulation of the spine and extremities
• Adjunctive procedures such as ultrasound, electrical muscle
stimulation, vibratory therapy, and cold pack application
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
Alternative treatments
No benefit All charges
Not covered:
•
Naturopathic services
•
Hypnotherapy
•
Biofeedback
All charges
Educational classes and programs
Coverage is provided for:
• Diabetic outpatient self-management training and education
• Health Education such as instructions on achieving and maintaining
physical and mental health, and preventing illness and injury and
childhood obesity education.
• Nutritional counseling provided by a Registered Dietician or
Participating Physician in connection with diabetes, coronary artery
disease and hyperlipidemia.
In-Network: Nothing
Out of Network: Not covered
Tobacco cessation programs, including individual/group/telephone
counseling, and for over the counter (OTC) and prescription drugs
approved by the FDA to treat tobacco dependence.
Benefits are limited to two quit attempts per
year. You pay nothing for OTC and
prescription drugs approved by the FDA to
treat tobacco dependence.
80 2013 Coventry Health Care HDHP Section 5(a)
HDHP Option
Benefit Description You pay
Medical Clinical Trial
If you are a participant in a clinical trial, we will provide related care if it
is not provided by the clinical trial as follows:
We provide coverage for Routine Patient Care Cost to a Member in a
Medical Clinical Trial for randomized and controlled Phase III treatment
of a life threatening disease, if such expenses are covered under this
agreement, and we authorize them in advance.
We provide coverage for Phase I and Phase II clinical trials and any
randomized and controlled clinical trial for treatment of cancer that are
sanctioned by the National Cancer Institute (NCI), or for the cost of any
investigational drug.
Treatment in a Medical Clinical Trial must be authorized in advance by
us.
See coverage limitations based on setting
(Inpatient, page 83; Outpatient, page 84; Home,
page 68 and Office, page 68, etc.), and type of
provider (Specialist care in office, hospital,
etc.)
81 2013 Coventry Health Care HDHP Section 5(a)
Section 5(b). Surgical and anesthesia services
provided by physicians and other health care professionals
HDHP Option
Important things you should keep in mind about these benefits:
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.
•Plan physicians must provide or arrange your care.
•The deductible is $2,000 for Self Only enrollment and $4,000 for Self and Family enrollment each
calendar year. The Self and Family deductible can be satisfied by one or more family members. The
deductible applies to almost all benefits in this Section.
•After you have satisfied your deductible, your Traditional medical coverage begins.
•Under your Traditional medical coverage, you will be responsible for your coinsurance amounts or
copayments for eligible medical expenses and prescriptions.
•The amounts listed below are for the charges billed by a physician or other health care professional
for your surgical care. Look in Section 5(c) for charges associated with the facility (i.e. hospital,
surgical center, etc.).
•YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME SURGICAL
PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure
which services require precertification and identify which surgeries require precertification.
Benefit Description You pay
Surgical procedures
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 morbid obesity (bariatric surgery)
- A condition in which an individual weighs 100 pounds or 100% over
his or her normal weight according to current underwriting standards;
eligible members must be age 18 or over.
- When we approve, we provide coverage for treatment of morbid
obesity through gastric bypass surgery or another surgical method that
is recognized by the National Institutes of Health as effective for the
long-term reversal of morbid obesity and consistent with criteria
approved by the National Institutes of Health.
- We provide benefits like any other medically necessary surgical
procedure for Members whose body mass index is greater than 40
kilograms per meter squared, or equal to or greater than 35 kilograms
per meter squared with a comorbid medical condition including
hypertension, cardiopulmonary condition, sleep apnea or diabetes.
- Body mass index is calculated by dividing the Member’s weight in
kilograms by the Member’s height in meters squared.
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
Surgical procedures - continued on next page
82 2013 Coventry Health Care HDHP Section 5(b)
HDHP Option
Benefit Description You pay
Surgical procedures (cont.)
• Insertion of internal prosthetic devices . See 5(a)
Orthopedic and
prosthetic devices
for device coverage information
• Voluntary sterilization (e.g., tubal ligation, vasectomy)
• Treatment of burns
Note: Generally, we pay for internal prostheses (devices) according to
where the procedure is done. For example, we pay Hospital benefits for
a pacemaker and Surgery benefits for insertion of the pacemaker.
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
Not covered:
•
Reversal of voluntary sterilization
•
Routine treatment of conditions of the foot; see Foot care
All charges
Reconstructive surgery
• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or illness if:
- the condition produced a major effect on the member’s appearance
and
- the condition can reasonably be expected to be corrected by such
surgery
• Surgery to correct a condition that existed at or from birth and is a
significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; and webbed fingers and toes.
• All stages of breast reconstruction surgery following a mastectomy,
such as:
- surgery to produce a symmetrical appearance of breasts;
- treatment of any physical complications, such as lymphedemas;
- breast prostheses and surgical bras and replacements (see Prosthetic
devices)
Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure.
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
Not covered:
•
Cosmetic surgery – any surgical procedure (or any portion of a
procedure) performed primarily to improve physical appearance
through change in bodily form, except repair of accidental injury
•
Surgeries related to sex transformation
All charges
83 2013 Coventry Health Care HDHP Section 5(b)
HDHP Option
Benefit Description You pay
Oral and maxillofacial surgery
Oral surgical procedures, limited to:
• Reduction of fractures of the jaws or facial bones;
• Surgical correction of cleft lip, cleft palate or severe functional
malocclusion;
• Removal of stones from salivary ducts;
• Excision of leukoplakia or malignancies;
• Excision of cysts and incision of abscesses when done as independent
procedures; and
• Other surgical procedures that do not involve the teeth or their
supporting structures.
• TMJ related services (non-dental)
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
Not covered:
•
Oral implants and transplants
•
Procedures that involve the teeth or their supporting structures (such
as the periodontal membrane, gingiva, and alveolar bone)
All charges
Organ/tissue transplants
These solid organ transplants are subject to medical neccessity and
experimental/investigational review by the Plan. Refer to
Other services
in Section 3 for prior authorization procedures. Transplant services must
be performed at a participating Center of Excellence. We approve and
designate where all transplants must be performed including hospitals
for specific transplant procedures. If you would like to know about a
specific facility, please contact Customer Service.
Solid organ transplants imited to:
• Cornea
• Heart
• Heart
• Lung: single/bilateral/lobar
• Kidney
• Kidney/Pancreas
• Liver
• Pancreas
• Autologous pancreas islet cell transplant (as an adjunct to total or near
total pancreatectomy) only for patients with chronic pancreatitis
• Intestinal transplants
- Small intestine
- Small intestine with the liver
- Small intestine with multiple organs, such as the liver, stomach, and
pancreas
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
Organ/tissue transplants - continued on next page
84 2013 Coventry Health Care HDHP Section 5(b)
HDHP Option
Benefit Description You pay
Organ/tissue transplants (cont.)
Blood or marrow stem cell transplants limited to the stages of the
following diagnoses: (the medical necessity limitation is considered
satisfied if the patient meets the staging description)
• Allogeneic transplants for
- Acute lymphocytic or non-lymphocytic (i.e., myelogeneous)
leukemia
- Chronic lymphocytic leukemia/small lymphocytic lymphoma
(CLL/SLL)
- Advanced Hodgkin’s lymphoma with reoccurence
- Advanced non-Hodgkin’s lymphoma with reoccurence
- Marrow failure and related disorders (i.e. Fanconi's PNH, pure red
cell aplaisia)
- Chronic myleogenous leukemia
- Hemoglobinopathies
- Myelodysplasia/Myelodysplastic syndromes
- Severe combined immunodeficiency
- Severe or very severe aplastic anemia
- Amyloidosis
- Paroxysmal Nocturnal Hemoglobinuria
• Autologous transplant for
- Acute lymphocytic or nonlymphocytic (i.e., myelogenous)
leukemia
- Advanced Hodgkin’s lymphoma with reoccurence
- Advanced non-Hodgkin’s lymphoma with reoccurence
- Neuroblastoma
- Amyloidosis
• Autologous tandem transplants for
- Recurrent germ cell tumors (including testicular cancer)
- Multiple myeloma
- Denovo myeloma
Blood or marrow stem cell transplants for
• Allogeneic transplants for
- Phagocytic/Hemophagocytic deficiency diseases (e.g., Wiskott-
Aldrich syndrome)
- Advanced neuroblastoma
- Infantile malignant osteoporosis
- Kostmann’s syndrome
- Leukocyte adhesion deficiencies
- Mucolipidosis (e.g., Gaucher’s disease, metachromatic
leukodystrophy, adrenoleukodystrophy)
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
Organ/tissue transplants - continued on next page
85 2013 Coventry Health Care HDHP Section 5(b)
HDHP Option
Benefit Description You pay
Organ/tissue transplants (cont.)
- Mucopolysaccharidosis (e.g., Hunter’s syndrome, Hurler’s
syndrome, Sanfilippo’s syndrome, Maroteaux-Lamy syndrome
variants)
- Myeloproliferative disorders
- Sickle cell anemia
- X-linked lymphoproliferative syndrome
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
Autologous transplants for
- Multiple myeloma
- Testicular, mediastinal, retroperitoneal, and ovarian germ cell
tumors
- Breast cancer
- Epithelial ovarian cancer
- Ependymoblastoma
- Ewing ’s sarcoma
- Medulloblastoma
- Pineoblastoma
- Waldenstrom's macroglobulinemia
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
Mini-transplants (nonmyeloblative, reduced intensity conditioning) for
covered tranplants: Subject to medical necessity. Refer to
Other services
in Section 3 for prior authorization procedures.
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
Tandem transplants for covered transplants: Subject to medical
necessity. Refer to
Other services
in Section 3 for prior authorization
procedures.
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
These blood or marrow stem cell transplants covered only in a National
Cancer Institute or National Institutes of Health approved clinical trial at
a Plan-designated center of excellence and 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 neccessary (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
- Chronic lymphocytic leukemia/small lymphocytic lymphoma
(CLL/SLL)
- Hemoglobinopathies
- Early stage (indolent or non-advanced) small cell lymphocytic
lymphoma
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
Organ/tissue transplants - continued on next page
86 2013 Coventry Health Care HDHP Section 5(b)
HDHP Option
Benefit Description You pay
Organ/tissue transplants (cont.)
- Myelodysplasia/Myelodysplastic syndromes
- Multiple myeloma
- Multiple sclerosis
• Nonmyeloablative allogeneic transplants or Reduced intensity
conditioning (RIC) for
- Acute lymphocytic or non-lymphocytic (i.e., myelogenous)
leukemia
- Myelodysplasia/Myelodysplastic syndromes
- Advanced Hodgkin’s lymphoma with reoccurrence
- Advanced non-Hodgkin’s lymphoma with reoccurrence
- Breast cancer
- Chronic lymphocytic leukemia
- Chronic myelogenous leukemia
- Colon cancer
- Early stage (indolent or non-advanced) small cell lymphocytic
lymphoma
- Chronic lymphocytic leukemia/small lymphocytic lymphoma
(CLL/SLL)
- Multiple myeloma
- Multiple sclerosis
- Myeloproliferative disorders
- Non-small cell lung cancer
- Ovarian cancer
- Prostate cancer
- Renal cell carcinoma
- Sarcomas
- Sickle Cell disease
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
• Autologous transplants for
- Advanced Childhood kidney cancers
- Advanced Ewing sarcoma
- Breast Cancer
- Childhood rhabdomyosarcoma
- Chronic lymphocytic leukemia
- Chronic myelogenous leukemia
- Chronic lymphocytic lymphoma/small lymphocytic lymphoma
(CLL/SLL)
- Early state (indolent or non-advanced) small cell lymphonic
lymphoma
- Epithelial Ovarian Cancer
- Multiple sclerosis
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
Organ/tissue transplants - continued on next page
87 2013 Coventry Health Care HDHP Section 5(b)
HDHP Option
Benefit Description You pay
Organ/tissue transplants (cont.)
- Mantle Cell (Non-Hodgkin lymphoma)
- Small cell lung cancer
- Systemic lupus erythematosus
- Systemic sclerosis
• 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 acutal solid organ
donor or up to four bone marrow/stem cell transplant donors in addition
to the testing of family members.
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
Not covered:
•
Implants of artificial organs
•
Transplants not listed as covered
All charges
Anesthesia
Professional services provided in –
• Hospital (inpatient)
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
Professional services provided in –
• Hospital outpatient department
• Skilled nursing facility
• Ambulatory surgical center
• Office
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
88 2013 Coventry Health Care HDHP Section 5(b)
Section 5(c). Services provided by a hospital or other facility,
and ambulance services
HDHP Option
Important things you should keep in mind about these benefits:
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary .
•Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.
•The deductible is $2,000 for Self Only enrollment and $4,000 for Self and Family enrollment each
calendar year. The Self and Family deductible can be satisfied by one or more family members.
The deductible applies to all benefits in this Section.
•After you have satisfied your deductible, your Traditional medical coverage begins.
•Under your Traditional medical coverage, you will be responsible for your coinsurance amounts or
copayments for eligible medical expenses and prescriptions.
•Be sure to read Section 4,
Your costs for covered services
for valuable information about how cost-
sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with
Medicare.
•The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center)
or ambulance service for your surgery or care. Any costs associated with the professional charge (i.
e., physicians, etc.) are in Sections 5(a) or (b).
•YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR HOSPITAL STAYS. Please
refer to Section 3 to be sure which services require precertification.
Benefit Description You pay
Inpatient hospital
Room and board, such as
• Ward, semiprivate, or intensive care accommodations
• General nursing care
• Meals and special diets
Note: If you want a private room when it is not medically necessary, you
pay the additional charge above the semiprivate room rate.
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
Other hospital services and supplies, such as:
• Operating, recovery, maternity, and other treatment rooms
• Prescribed drugs and medicines
• Diagnostic laboratory tests and X-rays
• Blood or blood plasma, if not donated or replaced
• Dressings , splints , casts , and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services
• Take-home items
• Medical supplies, appliances, medical equipment, and any covered
items billed by a hospital for use at home (Note: calendar year
deductible applies.)
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
Not covered:
•
Custodial care
All charges
Inpatient hospital - continued on next page
89 2013 Coventry Health Care HDHP Section 5(c)
HDHP Option
Benefit Description You pay
Inpatient hospital (cont.)
•
Non-covered facilities, such as nursing homes, schools
•
Personal comfort items, such as telephone, television, barber services,
guest meals and beds
•
Private nursing care
All charges
Outpatient hospital or ambulatory surgical center
• Operating, recovery, and other treatment rooms
• Prescribed drugs and medicines
• Diagnostic laboratory tests, X-rays , and pathology services
• Administration of blood, blood plasma, and other biologicals
• Pre-surgical testing
• Dressings, casts , and sterile tray services
• Medical supplies, including oxygen
• Anesthetics and anesthesia service
Note: We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do not cover the dental procedures.
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
Not covered: Blood and blood derivatives not replaced by the member All charges
Extended care benefits/Skilled nursing care facility
benefits
Covered up to 100 days per calendar year when full-time skilled nursing
care is necessary, and confinement in a skilled nursing facility is
medically appropriate as determined by a Plan doctor and approved by
the Plan.
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
Not covered: Custodial care All charges
Hospice care
Authorized within the service area for 30 days of inpatient care per
member. Includes the following:
• Part-time nursing care by or supervised by a registered graduate
nurse;
• Counseling, including dietary counseling, for the terminally ill
Member,
• Family counseling for the Immediate Family and the Family
Caregiver before the death of the terminally ill Member;
• Bereavement counseling for the Immediate Family or Family
Caregiver of the Member for at least the 6-month period following the
Member’s death or 15 visits, whichever occurs first;
• Respite Care subject to the following:
- The annual benefit shall be at least 14 days; and
- The carrier may limit any one inpatient stay for Respite Care to 5
consecutive days; and
Medical supplies, equipment, and medication required to maintain the
comfort and manage the pain of the terminally ill Member.
In-Network: All of our allowable amounts up to
the deductible amount and nothing thereafter
Out of Network: 30% of our allowance after
the calendar year deductible.
Hospice care - continued on next page
90 2013 Coventry Health Care HDHP Section 5(c)
HDHP Option
Benefit Description You pay
Hospice care (cont.)
Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when medically appropriate $100 copayment after the deductible
91 2013 Coventry Health Care HDHP Section 5(c)
Section 5(d). Emergency services/accidents
HDHP Option
Important things you should keep in mind about these benefits:
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.
•The deductible is $2,000 for Self Only enrollment and $4,000 for Self and Family enrollment each
calendar year. The Self and Family deductible can be satisfied by one or more family members.
The deductible applies to all benefits in this Section.
•After you have satisfied your deductible, your Traditional medical coverage begins.
•Under your Traditional medical coverage, you will be responsible for your coinsurance amounts and
copayments for eligible medical expenses and prescriptions.
•Be sure to read Section 4,
Your costs for covered services,
for valuable information about how cost-
sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with
Medicare.
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or
could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies
because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are
emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or
sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies – what
they all have in common is the need for quick action.
What to do in case of emergency:
In a life-threatening emergency, call the local emergency system (e.g. the local 911 telephone system), or go to the nearest
emergency facility. If an ambulance comes, tell the paramedics that the person who needs help is a Coventry Health Care
member.
Emergencies within our service area:
When a need for Emergency Services occurs in the Service Area, a member should seek medical attention immediately from
a hospital, physician’s office or other emergency facility. The determination of covered benefits for services rendered in an
emergency facility is based on our review of the member’s emergency room medical records, along with those relevant
symptoms and circumstances that preceded the provision of care. Services provided by an emergency facility for non-
Emergency Services are not covered except if you are directed to an emergency room by us or a physician and the care is
deemed not to be an emergency. Coverage will also be provided for Emergency Services in cases where you do not have 24-
hour access to a physician, even if those services are deemed not to be an emergency.
Emergencies outside our service area:
The member may be transported from outside the service area to the service area for continued medical management of an
emergency services condition at the option of the Medical Director or Medical Director’s Designee. We will only exercise
this option when the Medical Director or Medical Director’s Designee decides that such action will not have a detrimental
effect on the Member’s medical condition. Ground ambulance transportation to return a member to a participating provider
is covered when authorized by us. Refusal to be transferred may result in loss of benefits.
92 2013 Coventry Health Care HDHP Section 5(d)
HDHP Option
Benefit Description You pay
Emergency within our service area
• Emergency care at a doctor’s office
• Emergency care at an urgent care center
• Emergency care as an outpatient in a hospital, including doctors’
services
Note: We waive the ER copay if you are admitted to the hospital.
$100 copayment
Not covered: Elective care or non-emergency care All charges
Emergency outside our service area
• Emergency care at a doctor’s office
• Emergency care at an urgent care center
• Emergency care as an outpatient in a hospital, including doctors’
services
Note: We waive the ER copay if you are admitted to the hospital.
$100 copayment
Not covered:
•
Elective care or non-emergency care and follow-up care
recommended by non-Plan providers that has not been approved by
the Plan or provided by Plan providers
•
Emergency care provided outside the service area if the need for care
could have been foreseen before leaving the service area
•
Medical and hospital costs resulting from a normal full-term delivery
of a baby outside the service area
All charges
Ambulance
Professional ambulance service when medically appropriate.
Note: See 5(c) for non-emergency service.
$100 copayment
Not covered: Air ambulance All charges
93 2013 Coventry Health Care HDHP Section 5(d)
Section 5(e). Mental health and substance abuse benefits
HDHP Option
You need to get our approval for services and follow a treatment plan we approve in order to get
benefits. When you receive services as part of an approved treatment plan, cost-sharing and
limitations for Plan mental health and substance abuse benefits will be no greater than for similar
benefits for other illnesses and conditions.
Important things you should keep in mind about these benefits:
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.
•The calendar year deductible or, for facility care, the inpatient deductible, applies to almost all
benefits in this Section. We added "(No deductible)" to show when a deductible does not apply.
•Be sure to read Section 4,
Your costs for covered services,
for valuable information about how cost-
sharing works. Also read Section 9 about coordinating benefits with other coverage, including with
Medicare.
•YOU MUST GET PREAUTHORIZATION FOR THESE SERVICES. Benefits are payable
only when we determine that care is clinically appropriate to treat your condition and only when you
receive the care as part of a treatment plan that we approve. The treatment plan may include
services, drugs, and supplies described elsewhere in this brochure. To be eligible to receive full
benefits, you must follow the preauthorization process and get Plan approval of your treatment plan.
We will provide medical review criteria or reasons for treatment plan denials to enrollees, members
or providers upon request or as otherwise required.
•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 plan in favor of another.
Benefit Description You pay
Professional services
When part of a treatment plan we approve, we cover professional
services by licensed professional mental health and substance abuse
practioners when acting within the scope of their license, such as
psychiatrists, psychologists, clinical social workers, licensed
professional counselors, or marriage and family therapists.
Diagnosis and treatment of psychiatric conditions, mental illness, or
mental discorders. Services include:
• Diagnostic evaluation
• Crisis intervention and stabilization for acute episodes
• Medication evaluation and management (pharmacotherapy)
• Pyschological and neuropsychological testing necessary to determine
the appropriate psychiatric treatment
• Treatment and counseling (including individual or group therapy
visits)
• Diagnostic and treatment of alcoholism and drug abuse, including
detoxification, treatment and counseling
• Professional charges for intensive outpatient treatment in a provider's
office or other professional setting
• Electroconvulsive therapy
Your cost-sharing responsibilities are no greater
than for other illnesses or conditions
94 2013 Coventry Health Care HDHP Section 5(e)
HDHP Option
Benefit Description You pay
Diagnostics
Outpatient diagnostic tests provided and billed by a licensed mental
health and substance abuse practitioner
Outpatient diagnostic tests provided and billed by a laboratory, hospital
or other covered facility
Inpatatient diagnostic tests provided and billed by a hospital or other
covered facility
In-Network: All of our allowable amounts up
to the deductible amount and nothing thereafter
Out of Network: 30% of our allowable after
the calendar year deductible
Nothing for inpatient tests
Inpatient hospital or other covered facility
Inpatient services provided and billed by a hospital or other covered
facility
• Room and board, such as semiprivate or intensive accommodations,
general nursing care, meals and special diets, and other hospital
services
In-Network: All of our allowable amounts up
to the deductible amount and nothing thereafter
Out of Network: 30% of our allowable after
the calendar year deductible
Outpatient hospital or other covered facility
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
Not covered: Services we have not approved
In-Network: Nothing for services provided in
an out-patient setting
Out of Network: 30% of our allowable after
the calendar year deductible
To be eligible to receive these benefits you must obtain a treatment plan and follow all of
the following network authorization processes:
MHNet Behavioral Health is contracted by CHCDE to provide a network of providers
who offer a variety of therapeutic services on an inpatient and outpatient basis. All
inpatient and outpatient treatment must be authorized by MHNet at 866-808-2808 or
800-862-2244 (for the deaf and hard of hearing).
Preauthorization
We may limit your benefits if you do not obtain a treatment plan. Limitation
95 2013 Coventry Health Care HDHP Section 5(e)
Section 5(f). Prescription drug benefits
HDHP Option
Here are some important things to keep in mind about these benefits:
•We cover prescribed drugs and medications, as described in the chart beginning on the next page.
•Please remember that all benefits are subject to the definitions, limitations and exclusions in this
brochure and are payable only when we determine they are medically necessary.
•The deductible is $2,000 for Self Only enrollment and $4,000 for Self and Family enrollment each
calendar year. The Self and Family deductible can be satisfied by one or more family members.
The deductible applies to all benefits in this Section.
•After you have satisfied your deductible, your Traditional medical coverage begins.
•Under your Traditional medical coverage, you will be responsible for your coinsurance amounts for
eligible medical expenses or copayments for eligible prescriptions.
•Be sure to read Section 4,
Your costs for covered services,
for valuable information about how cost-
sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with
Medicare.
There are important features you should be aware of. These include:
•Who can write your prescription. You may obtain a prescription from a prescribing physician or other health care
professional who is licensed and who, in the usual course of business, may legally prescribe prescription drugs.
•Where you can obtain them. You may fill the prescription at a participating pharmacy, including a participating mail
order or specialty pharmacy, except for Emergency or Urgent Care Services, out of the service area. A “specialty
pharmacy” is a pharmacy from which you may obtain self-administered injectable drugs. You may obtain maintenance
medication through Medco Health Solutions, our mail order prescription program. Medco's Customer Service number is
800-378-7040.
•We use a formulary. A formulary is a list of specific generic and brand name prescription drugs authorized by the Health
plan and subject to periodic review and modification. Since there may be more than one brand name of a prescription
drug, not all brands of the same prescription drug may be included in the formulary. If you would like information on
whether a specific drug is included in our drug formulary, please call our Customer Service Department at 302-283-6500
within our service area or 800-833-7423.
•Tier 1A formulary medications. Tier 1A is a list of specific generic medications that are available to you at a reduced
copayment. To view and download the specific list of Tier 1A medications, go to www.chcde.com, plan members, and
select the section entitled Federal & Postal employees.
•There are dispensing limitations. These are the dispensing and quantity limitations. Prescription drugs will be
dispensed in the quantity determined by Us. In order for Prescription Drugs to be covered in excess of the specific
quantity limit, your physician must call Us before you fill the Prescription Order or Refill for a drug that exceeds the
specific quantity limit.
Dispensing limits are described below:
Retail Drugs
In general, the quantity of a Prescription Drug dispensed by a Retail Pharmacy for each Prescription Order or Refill is limited
to the lesser of:
•The amount determined by Us to be a 30-day supply
•The amount prescribed in the Prescription Order or Refill; or
•Depending on the form and packaging of the product, the following:
- 100 tablets/capsules, or
- 480 cc of oral liquids; or
- A single commercially prepackaged item (including but not limited to inhalers, topicals, and vials).
96 2013 Coventry Health Care HDHP Section 5(f)
HDHP Option
Mail Order Drugs
The quantity of a Prescription Drug dispensed by the Mail Order Pharmacy for one Prescription Order or Refill for a
Maintenance Drug is limited to the lesser of:
•The amount prescribed in the Prescription Order or Refill; or
•The amount determined by Us to be Medically Necessary; or
•The amount determined by Us to be a 90-day supply; or
•Depending on the form and packaging of the product, the following:
- 300 tablets/capsules, or
- 1,440 cc of oral liquids; or
- three (3) single commercially prepackaged items (including but not limited to inhalers, topicals, and vials).
The following Member payments shall apply:
1. One (1) copayment (i.e. $3 for Tier 1A (a list of specific generic medications)), $15 for Tier 1, $30 for Tier 2 (prescription
drugs we have designated as Tier 2), $60 for Tier 3 (prescription drugs that are not otherwise designated as Tier 1 or Tier 2,
including brand name and generic prescription drugs that are not on our drug formulary) or the cost of the prescription
drug, whichever is less, is due each time a prescription is filled or refilled at a retail or specialty pharmacy.
2. Formulary maintenance drugs obtained through a mail order pharmacy designated by the Health Plan may be dispensed
with two (2) copayments for a ninety- (90) day’s supply (i.e. $6 for Tier 1A (a list of specific generic medications)), $30 for
Tier 1, $60 for Tier 2 (prescription drugs we have designated as Tier 2), $120 for Tier 3 (prescription drugs that are not
otherwise designated as Tier 1 or Tier 2, including brand name and generic prescription drugs that are not on our drug
formulary). To order prescription drugs or refills please contact Medco’s Customer Service at 800-378-7040. This
service is available 24 hours a day – 7 days a week.
3. Total member payments shall not exceed the price of the prescription drug. Copayments and Ancillary Charges do not
apply do the member’s Out-of-Pocket Maximum.
A generic equivalent will be dispensed if it is available. If the brand name prescription drug is dispensed and an equivalent
generic prescription drug is available, the member shall pay an “ancillary charge” in addition to the brand name copayment.
The ancillary charge will be due regardless of whether or not the prescribing physician indicates that the pharmacy is to
“Dispense as Written.” The Ancillary Charge is the difference between the price of the brand name and generic.
Why use generic drugs? Generic drugs are lower-priced drugs that are the therapeutic equivalent to more expensive brand-
name drugs. They must contain the same active ingredients and must be equivalent in strength and dosage to the original
brand-name product. Generics cost less than the equivalent brand-name product. The U.S. Food and Drug Administration
sets quality standards for generic drugs to ensure that these drugs meet the same standards of quality and strength as brand-
name drugs.
•You can save money by using generic drugs. However, you and your physician have the option to request a name brand if
a generic option is available. Using the most cost-effective medication saves money.
When you do have to file a claim? When you receive drugs from a plan pharmacy you do not have to file a claim. For a
covered out-of –area emergency, you will need to file a claim when you receive drugs from a non-plan pharmacy. To file a
pharmacy claim, call Medco at 800-378-7040.
97 2013 Coventry Health Care HDHP Section 5(f)
HDHP Option
Benefit Description You pay
Covered medications and supplies
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
• Disposable needles and syringes for the administration of
covered medications
• Drugs for sexual dysfunction (see prior authorization below)
• Contraceptive drugs and devices
• Self-Administered injectable Prescription that include but are
not limited to the following: multiple sclerosis agents, growth
hormones, colony stimulating factors given more than once
monthly, chronic medications for hepatitis C, certain
rheumatoid arthritis medications, certain injectable HIV drugs,
certain osteoporosis agents, and heparin products. Self
Administered Injectable drugs are only available through
Specialty Pharmacies. The following are not considered Self-
Administered Injectable Drugs because they are not obtained
from a Specialty Pharmacy: insulin, glucagon, and bee sting
kits, Imitrex and injectable contraceptives.
• Tier 1A formulary medications. Tier 1A is a list of specific
generic medications that are available to you at a reduced
copayment. To view and download the specific list of Tier 1A
medications, go to www.chcde.com, plan members, and select
the section entitled Federal & Postal employees.
Note: If there is no generic equivalent available, you
will still have to pay the name brand copay.
In-Network: you pay all charges up to the
calendar year deductible and then the below
copays thereafter.
Retail and Specialty Pharmacy:
$3 per prescription or refill for Tier 1A (a list of
specific formulary generic medications)
$15 per prescription or refill for Tier 1 formulary
medications
$30 per prescription or refill for Tier 2 formulary
medications
$60 per prescription or refill for Tier 3 non-formulary
medications
Mail Order (Maintenance drugs only):
$6 per prescription or refill for Tier 1A formulary (a
list of specific formulary generic medications)
$30 per prescription or refill for a 90 consecutive day
supply for Tier 1 formulary medications
$60 per prescription or refill for a 90 consecutive day
supply for Tier 2 formulary medications
$120 per prescription or refill for Tier 3 non-
formulary medications
Out-of-Network: Not Covered
Women's contraceptive drugs and devices Nothing
Not covered:
•
Compounded prescriptions whose only ingredients do not
require prescription
•
Legend drugs for which there is a non-prescription equivalent
such as vitamins, except legend prenatal vitamins for pregnant/
nursing females, liquid or chewable legend pediatric vitamins
for children under age 13, and potassium supplements to
prevent/treat low potassium
•
Prescription Drugs and supplies for cosmetic purposes
•
Drugs to enhance athletic performance
•
Dietary supplements, appetite suppressants, and other drugs
used to treatment obesity or assist in weight reduction
•
Drugs obtained at a non-Plan pharmacy; except for out-of-area
emergencies
•
Vitamins, nutrients and food supplements even if a physician
prescribes or administers them, except as specified herein
All charges
Covered medications and supplies - continued on next page
98 2013 Coventry Health Care HDHP Section 5(f)
HDHP Option
Benefit Description You pay
Covered medications and supplies (cont.)
•
Nonprescription medicines
•
Charges for special re-packaging of medications prepared by
the pharmacy such as “unit dose” or “bubble pack”
•
Oral dental preparations, fluoride rinses, except fluoride tablets
or drops
•
Refill prescriptions resulting from loss or theft
Note: Over-the-counter and prescription drugs approved by the
FDA to treat tobacco dependence are covered under the Tobacco
cessation benefit and require a written prescription by an approved
provider. (see Educational classes and Programs, page 74 ).
All charges
99 2013 Coventry Health Care HDHP Section 5(f)
Section 5(g). Dental benefits
HDHP Option
Important things you should keep in mind about these benefits:
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.
•If you are enrolled in a Federal Employees Dental /Vision Insurance Program (FEDVIP) Dental
plan, your FEHB Plan will be First/Primary payor of any Benefit payments and your FEDVIP Plan
is secondary to your FEHB Plan. See Section 9 Coordinating benefits with other coverage.
•Plan dentists must provide or arrange your care.
•The deductible is $2,000 for Self Only enrollment and $4,000 for Self and Family enrollment each
calendar year. The Self and Family deductible can be satisfied by one or more family members.
The deductible applies to all benefits in this Section.
•After you have satisfied your deductible, your Traditional medical coverage begins.
•Under your Traditional medical coverage, you will be responsible for your coinsurance amounts and
copayments for eligible medical expenses and prescriptions.
•We cover hospitalization for dental procedures only when a non-dental physical impairment exists
which makes hospitalization necessary to safeguard the health of the patient. See Section 5(c) for
inpatient hospital benefits. We do not cover the dental procedure unless it is described below.
•Be sure to read Section 4,
Your costs for covered services,
for valuable information about how cost-
sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with
Medicare.
Accidental injury benefit You Pay
Nothing after the deductible We cover restorative services and supplies necessary to promptly repair (but
not replace) sound natural teeth. The need for these services must result from
an accidental injury.
Dental benefits
All charges
We have no other dental benefits
100 2013 Coventry Health Care HDHP Section 5(g)
Section 5(h). Special features
HDHP Option
Feature Description
Feature
Flexible benefits optionUnder the flexible benefits option, we determine the most effective way to
provide services.
• We may identify medically appropriate alternatives to regular contract
benefits as a less costly alternative. If we identify a less costly alternative,
we will ask you to sign an alternative benefits agreement that will include all
of the following terms in addition to other terms as necessary. Until you
sign and return the agreement, regular contract benefits will continue.
• Alternative benefits will be made available for a limited time period and are
subject to our ongoing review. You must cooperate with the review process.
• By approving an alternative benefit we do not guarantee you will get it in
the future.
• The decision to offer an alternative benefit is solely ours, and except as
expressly provided in the agreement, we may withdraw it at any time and
resume regular contract benefits.
• If you sign the agreement we will provide the agreed-upon alternative
benefits for the stated time period (unless circumstances change). You may
request and 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).
Wellness ProgramsCoventry Health Care, Inc. offers an on-line wellness program called
Wellbeing.
Wellbeing is a free service available only to Coventry Health Care
members. This on-line tool available through our website, www.chcde.com/
wellbeing. This program allows Coventry members to utilize the MyEPHIT
tool to develop a customized exercise, nutrition or personal improvement
program with the assistance of on-line fitness experts. This online Personal
Health Improvement Training program is designed to enhance your overall
Wellbeing. Through Wellbeing, you can:
• Customize a daily fitness routine, including on-line demonstrations of
specific exercises.
• Personalize a nutrition plan, including receiving a meal planner with menus
and shopping lists.
• Download materials on life skills management, and family activity planning.
• Communicate on-line with a Certified personal trainer, registered dieticians,
and psychologists.
• Download recipes for healthy menus.
• Discover online family programs through KidPHIT and TeenPHIT, which
allows your children to become motivated for a healthier lifestyle.
• Earn REWARDS! Through the Wellbeing program, just by signing on every
month, you will be entered into a monthly drawing for prizes such as
mountain bikes, DVD players, and other fitness related prizes!
Feature - continued on next page
101 2013 Coventry Health Care HDHP Section 5(h)
HDHP Option
Feature Description
Feature (cont.)
• Earn points towards the purchase of discounted fitness items. Through the
online My EPHIT Mall, members can use the points they earn on the
website to purchase items such as Yoga Mats, vitamins, or workout videos.
Travel benefit/services overseasYour Benefit Plan does not include out-of-network benefits, however; if you
are out of our service area and in need of Urgent or Emergent Care; please call
1-800-639-9154 for a First Health network provider in your area.
102 2013 Coventry Health Care HDHP Section 5(h)
Section 5(i). Health education resources and account management tools
HDHP Option
Special features Description
Visit the Health Information section of our website at www.chcde.com for information to
help you take command of your health. The site is organized in simple, user-friendly,
sections:
Assess Your Health
- where you will find a simple, free, online health risk assessment
tool to benchmark your wellness, and better understand your overall health status and
risks.
About Your Health
- for information about a specific condition or general preventive
guidelines.
WebMD
- our link to this health site also provides wellness and disease information to
help improve health.
Prescription Drug -
educational materials are also accessible through our website,
through a link to our pharmacy benefit manager, Caremark. There, you will find:
• detailed information about a wide range of prescription drugs;
• a drug interaction tool to help easily determine if a specific drug can have any adverse
interactions with each other, with over-the-counter drugs, or with herbals and
vitamins;
• facts about why FDA-approved generic drugs should be a first choice for effective,
economical treatment.
Another key health information tool that we make available to you is our online quality
tool, powered by HealthShareÒ. You can review the frequency of procedures performed
by a provider, knowing the correlation between frequency of service and quality of
outcomes. We post additional quality outcome information, such as re-admission rates
within 30 days, postoperative complications, and even death rates.
We also publish an e-newsletter to keep you informed on a variety of issues related to
your good health. Visit our Web site at www.chcde.com for back editions of this
publication,
Living Well
.
In addition, we augment our health education tools with access to our
Nurse Advisor
Services
. Experienced RNs are available through an inbound call center 24x7x365 to
assist you and help you to maximize your benefits, by providing clinical and economic
information to make an informed decision on how to proceed with care.
Health education
resources
For each HSA and HRA account holder, we maintain a complete claims payment history
online through Coventry Health Care’s password-protected, self-service functionality, My
Online Services, at www.chcde.com.
You will receive an
Explanation of Benefits
(EOB) after every claim.
If you have an HSA,
• You may also access your account on-line at www.chcde.com
.
If you have an HRA,
• Your HRA balance will be available online through www.chcde.com
• Your balance will also be shown on your EOB form
Account management
tools
• As a member of this HDHP, you may choose any provider. However, you will receive
discounts when you see a network provider. Directories are available online at www.
chcde.com.
103 2013 Coventry Health Care HDHP Section 5(i)
HDHP Option
• As a member of this HDHP, you may choose any provider. However, you will receive
discounts when you see a network provider. Our provider search function on our
website www.chcde.com is updated every week. It lets you easily search for a
participating physician based on the criteria
you
choose, such as provider specialty,
gender, secondary languages spoken, or hospital affiliation. You can even specify the
maximum distance you are willing to travel and, in most instances, get driving
directions and a map to the offices of identified providers.
• Pricing information for medical care is available at www.chcde.com. There, you will
find our
Health Services Pricing Tools
, which provide average cost information for
some the most common categories of service. The easy-to-understand information is
sorted by categories of service, including physician office visits, diagnostic tests,
surgical procedures, and hospitalization.
• Pricing information for prescription drugs is available through our link to the website
of our pharmacy benefit manager, Medco (which you can access via www.chcde.com).
Through a password-protected account, you will have the ability to estimate
prescription costs before ordering.
Educational materials on the topics of HSAs, HRAs and HDHPs are available at www.
chcde.com. Pricing information for medical care is available at www.chcde.com. Pricing
information for prescription drugs is available at www.chcde.com.
Link to online pharmacy through www.chcde.com.
Educational materials on the topics of HSAs, HRAs and HDHPs are available at www.
chcde.com
Consumer choice
information
• Our complex case management programs offer special assistance to members with
intricate, long-term medical needs. Our disease management program fosters a
proactive approach to managing care from prevention through treatment and
management. Your physician can help arrange for participation in these programs, or
you can simply contact our member service department.
• Patient safety information is available online at www.chcde.com.
Care support is also available to you, in the form of a relationship that we have established
with the
College of American Pathologists
for e-mail reminder notifications. We will send
a message to the e-mail address you provide on a scheduled basis, reminding you to
arrange for screening tests.
Care support
104 2013 Coventry Health Care HDHP Section 5(i)
Section 6. General exclusions – services, drugs, and supplies we do not cover.
The exclusions in this section apply to all benefits. There may be other exclusions and limitations listed in Section 5 of this
brochure. Although we may list a specific service as a benefit, we will not cover it unless it is medically necessary to
prevent, diagnose, or treat your illness, disease, injury or condition. For information on obtaining prior approval for
specific services, such as transplants, see Section 3
When you need prior Plan approval for certain services.
We do not cover the following:
•Care by non-plan providers except for authorized referrals or emergencies (see
Emergency services/accidents
).
•Services, drugs, or supplies you receive while you are not enrolled in this Plan.
•Services, drugs, or supplies not medically necessary.
•Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice.
•Experimental or investigational procedures, treatments, drugs or devices (see specifics regarding transplants).
•Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were
carried to term, or when the pregnancy is the result of an act of rape or incest.
•Services, drugs, or supplies related to sex transformations.
•Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program, or
•Services, drugs, or supplies you receive without charge while in active military service.
•Extra care 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 related to conducting the clinical trial such as research, physician and nurse time, analysis of results and
clinical tests performed only for research purposes.
•Applied Behavior Analysis
105 2013 Coventry Health Care Section 6
Section 7. Filing a claim for covered services
This Section primarily deals with post-service claims (claims for services, drugs or supplies you have already received). See
Section 3 for information on pre-service claims procedures (services, drugs or supplies requiring prior Plan approval)
including urgent care claims procedures. When you see Plan physicians, receive services at Plan hospitals and facilities, or
obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and
pay your copayment, coinsurance, or deductible.
You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these providers
bill us directly. Check with the provider. If you need to file the claim, here is the process:
To obtain claim forms or other claims filing advice or answers about our benefits, call our
Customer Service Department at 302-283-6500 within the service area or 800-833-7423
or log on our Web site at www.chcde.com.
In most cases, providers and facilities file claims for you. Your physician must file on the
form CMS-1500, Health Insurance Claim Form. Your facility must file on the UB-04
form. For claims questions and assistance, call us at 302-283-6500.
When you must file a claim – such as for services you receive outside of 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 and ID number, date of birth address and phone number
• Name and address of the physician or facility that provided the service or supply
• Dates you received the services or supplies
• Diagnosis
• Type of each service or supply
• A copy of the explanation of benefits, payment, or denial from any primary payor such
as the Medicare Summary Notice (MSN)
• The charge for each service or supply
• Receipts, if you paid for your services.
Note: canceled checks, cash register receipts, or balance due statements are not acceptable
substitutes for itemized bills.
Mail the claim to:
Medical & Hospital Benefits:
Coventry Health Care
PO Box 7712
London, KY 40742
Prescription Drugs:
Medco Health Solutions
P.O. Box 14711
Lexington, KY 40512
800-378-7040
Mental Health and Substance Abuse:
MHNet Behavioral Health
PO Box 209010
Austin, TX 78720
Medical and hospital
benefits
106 2013 Coventry Health Care Section 7
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.
Deadline for filing your
claim
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 as long as we 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.
Post-service claims
procedures
You may designate an authorized representative to act on your behalf for filing a claim or
to appeal claims decisions to us. For urgent care claims, we will permit a health care
professional with knowledge of your medical condition to act as your authorized
representative without your express consent. For the purposes of this section, we are also
referring to your authorized representative when we refer to you.
Authorized
Representative
If you live in a county 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 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 health care provider, and the claim amount, if
applicable), and a statement describing the availability, upon request, of the diagnosis and
procedure codes.
Notice Requirements
107 2013 Coventry Health Care Section 7
Section 8. The disputed claims process
You may be able to appeal directly to the Office of Personnel Management (OPM) if we do not follow required claims
processes. For more information about situations in which you are entitled to immediately appeal to OPM, including
additional requirements not listed in Sections 3, 7 and 8 of this brochure, please visit www.chcde.com.
Please follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on
your post-service (a claim or request for services, drugs, or supplies have already been provided). In Section 3
If you
disagree with our pre-service claim decision,
we describe the process you need to follow if you have a claim for service,
referrals, drugs or supplies that must have prior Plan approval, such as inpatient hospital admissions.
To help you prepare your appeal, you may arrange with us to review and copy, free of charge, all relevant material and Plan
documents under our control relating to your claim, including those that involve any expert review(s) of your claim.
To make your request, please contact our Customer Service Department by writing Coventry Health Care, 750 Prides
Crossing, Suite 300, Newark, DE 19713 or calling 800-833-7423.
Our reconsideration will take into account all comments, documents, records, and other information submitted by you
relating to the claim, without regard to whether such information was submitted or considered in the initial benefit
determination.
When our initial decision is based (in whole or in part) on a medical judgment (i.e., medical necessity, experimental/
investigational), we will consult with a health care professional who has appropriate training and experience in the field of
medicine involved in the medical judgment and who was not involved in making the initial decision.
Our reconsideration decision will not afford deference to the initial decision and will be conducted by a plan representative
who is neither the individual who made the initial decision that is the subject of the reconsideration, nor the subordinate of
that individual.
We will not make our decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect
to any individual (such as a claims adjudicator or medical expert) based upon the likelihood that the individual will support
the denial of benefits.
Disagreements between you and the CDHP or HDHP fiduciary regarding the administration of an HSA or HRA are not
subject to the disputed claims process.
Description Step
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: Coventry Health Care, 750 Prides Crossing, Suite 300, Newark, DE 19713; 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 providing your email address, you may be able to provide our decision quicker.
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 or reconsideration. You may respond to that
new evidence or rationale at the OPM review stage described in Step 2.
1
108 2013 Coventry Health Care Section 8
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 30 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.
2
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 Health Insurance 3 (HI3), 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 physicians' letters, operative reports, bills, medical
records, and explanation of benefits (EOB) forms;
• Copies of all letters you sent to us about the claim;
• Copies of all letters we sent to you about the claim; and
• Your daytime phone number and the best time to call.
• Your email address, if you would like to receive OPM's decision via email. Please note that by providing
your email address, you may receive OPM's decision more quickly.
Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to
which claim.
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must include a copy of your specific written consent with the
review request. However, for urgent care claims, a health care professional with knowledge of your medical
condition may act as your authorized representative without your express consent.
Note: The above deadlines may be extended if you show that you were unable to meet the deadline because
of reasons beyond your control.
3
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 sue. If you decide to sue, you must file the
suit against OPM in Federal court by December 31 of the third year after the year in which you received the
disputed services, drugs, or supplies or from the year in which you were denied precertification or prior
approval. This is the only deadline that may not be extended.
OPM may disclose the information it collects during the review process to support their disputed claim
decision. This information will become part of the court record.
4
109 2013 Coventry Health Care Section 8
You may not sue 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 800-833-7423 We will hasten our review (if we have not yet responded to your
claim); or we will inform OPM so they can quickly review your claim on appeal. You may call OPM’s
Health Insurance 3 at (202) 606-0737 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 dependent 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 Worker’s Compensation programs if you are
receivingWorker’s Compensation benefits.
110 2013 Coventry Health Care Section 8
Section 9. Coordinating benefits with Medicare and other coverage
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
payor and the other plan pays a reduced benefit as the secondary payor. We, like other
insurers, determine which coverage is primary according to the National Association of
Insurance Commissioners’ (NAIC) guidelines. For more information on NAIC rules
regarding the coordinating of benefits, visit the NAIC we site at http://www.NAIC.org .
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 pays, we will pay what is left of our allowance, up to our regular benefit. We will not
pay more than our allowance.
When you have other
health coverage
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 the program.
TRICARE and
CHAMPVA
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.
Workers’ Compensation
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.
Medicaid
We do not cover services and supplies when a local, State, or Federal government agency
directly or indirectly pays for them.
When other Government
agencies are responsible
for your care
111 2013 Coventry Health Care Section 9
When you receive money to compensate you for medical or hospital care for injuries or
illness caused by another person, you must reimburse us for any expenses we paid.
However, we will cover the cost of treatment that exceeds the amount you received in the
settlement.
If you do not seek damages you must agree to let us try. This is called subrogation. If you
need more information, contact us for our subrogation procedures.
When others are
responsible for injuries
Some FEHB plans already cover some dental and vision services. When you are covered
by more than one vision/dental plan, coverage provided under you FEHB plan remains as
your primary coverage. FEDVIP coverage pays secondary to that coverage. When you
enroll in a dental and/or vision plan on BENEFEDS.com, 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.
When you have Federal
Employees Dental and
Vision Insurance
Program (FEDVIP)
coverage
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, 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, this plan
does not cover these costs.
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.
Clinical trials
Medicare is a health insurance program for:
• People 65 years of age or older
• Some people with disabilities under 65 years of age
• People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a
transplant)
Medicare has four parts:
• Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or
your spouse worked for at least 10 years in Medicare-covered employment, you
should be able to qualify for premium-free Part A insurance. (If you were a Federal
employee at any time both before and during January 1983, you will receive credit for
your Federal employment before January 1983.) Otherwise, if you are age 65 or older,
you may be able to buy it. Contact 1-800-MEDICARE (1-800-633-4227), (TTY
1-877-486-2048) for more information.
• Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B
premiums are withheld from your monthly Social Security check or your retirement
check.
When you have Medicare
• What is Medicare?
112 2013 Coventry Health Care Section 9
• Part C (Medicare Advantage). You can enroll in a Medicare Advantage plan to get
your Medicare benefits. We offer a Medicare Advantage plan. Please review the
information on coordinating benefits with Medicare Advantage plans on the next page.
• Part D (Medicare prescription drug coverage). There is a monthly premium for Part D
coverage. If you have limited savings and a low income, you may be eligible for
Medicare’s Low-Income Benefits. For people with limited income and resources,
extra help in paying for a Medicare prescription drug plan is available. Information
regarding this program is available through the Social Security Administration (SSA).
For more information about this extra help, visit SSA online at www.socialsecurity.
gov, or call them at 1-800-772-1213 (TTY 1-800-325-0778). Before enrolling in
Medicare Part D, please review the important disclosure notice from us about the
FEHB prescription drug coverage and Medicare. The notice is on the first inside page
of this brochure. The notice will give you guidance on enrolling in Medicare Part D.
The decision to enroll in Medicare is yours. We encourage you to apply for Medicare
benefits 3 months before you turn age 65. It’s easy. Just call the Social Security
Administration toll-free number 1-800-772-1213 (TTY 1-800-325-0778) to set up an
appointment to apply. If you do not apply for one or more Parts of Medicare, you can still
be covered under the FEHB Program.
If you can get premium-free Part A coverage, we advise you to enroll in it. Most Federal
employees and annuitants are entitled to Medicare Part A at age 65 without cost. When
you don’t have to pay premiums for Medicare Part A, it makes good sense to obtain the
coverage. It can reduce your out-of-pocket expenses as well as costs to the FEHB, which
can help keep FEHB premiums down.
Everyone is charged a premium for Medicare Part B coverage. The Social Security
Administration can provide you with premium and benefit information. Review the
information and decide if it makes sense for you to buy the Medicare Part B coverage. If
you do not sign up for Medicare Part B when you are first eligible, you may be charged a
Medicare Part B late enrollment penalty of a 10% increase in premium for every 12
months you are not enrolled. If you didn't take Part B at age 65 because you were covered
under FEHB as an active employee (or you were covered under your spouse's group
health insurance plan and he/she was an active employee), you may sign up for Part B
(generally without an increased premium) within 8 months from the time you or your
spouse stop working or are no longer covered by the group plan. You also can sign up at
any time while you are covered by the group plan.
If you are eligible for Medicare, you may have choices in how you get your health care.
Medicare Advantage is the term used to describe the various private health plan choices
available to Medicare beneficiaries. The information in the next few pages shows how we
coordinate benefits with Medicare, depending on whether you are in the Original
Medicare Plan or a private Medicare Advantage plan.
• Should I enroll in
Medicare?
When we are the primary payor, we process the claim first. If you enroll in Medicare Part
D and we are the secondary payor, we will review claims for your prescription drug costs
that are not covered by Medicare Part D and consider them for payment under the FEHB
plan.
• Medicare prescription
drug coverage (Part
D)
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.
• The Original
Medicare Plan (Part
A or Part B)
113 2013 Coventry Health Care Section 9
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 800-833-7423 or see our Web site at www.chcde.com.
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.
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.
Tell us about your
Medicare coverage
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 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 Medicare Advantage plan: We do not have a Medicare Advantage
plan.
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), but 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.
• Medicare Advantage
(Part C)
114 2013 Coventry Health Care Section 9
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.
115 2013 Coventry Health Care Section 9
Medicare always makes the final determination as to whether they are the primary payor. The following chart illustrates
whether Medicare or this Plan should be the primary payor for you according to your employment status and other factors
determined by Medicare. It is critical that you tell us if you or a covered family member has Medicare coverage so we can
administer these requirements correctly. (Having coverage under more than two health plans may change the order of
benefits determined on this chart.)
Primary Payor Chart
A. When you - or your covered spouse - are age 65 or over and have Medicare and you... The primary payor for the
individual with Medicare is...
Medicare This Plan
1) Have FEHB coverage on your own as an active employee
2) Have FEHB coverage on your own as an annuitant or through your spouse who is an
annuitant
3) Have FEHB through your spouse who is an active employee
4) Are a reemployed annuitant with the Federal government and your position is excluded from
the FEHB (your employing office will know if this is the case) and you are not covered under
FEHB through your spouse under #3 above
5) Are a reemployed annuitant with the Federal government and your position is not excluded
from the FEHB (your employing office will know if this is the case) and...
• You have FEHB coverage on your own or through your spouse who is also an active
employee
• You have FEHB coverage through your spouse who is an annuitant
6) Are a Federal judge who retired under title 28, U.S.C., or a Tax Court judge who retired
under Section 7447 of title 26, U.S.C. (or if your covered spouse is this type of judge) and
you are not covered under FEHB through your spouse under #3 above
7) Are enrolled in Part B only, regardless of your employment status
for Part B
services
for other
services
8) Are a Federal employee receiving Workers' Compensation disability benefits for six months
or more
*
B. When you or a covered family member...
1) Have Medicare solely based on end stage renal disease (ESRD) and...
• 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
2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary and...
• 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
3) Have Temporary Continuation of Coverage (TCC) and...
• 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)
C. When either you or a covered family member are eligible for Medicare solely due to
disability and you...
1) Have FEHB coverage on your own as an active employee or through a family member who
is an active employee
2) Have FEHB coverage on your own as an annuitant or through a family member who is an
annuitant
D. When you are covered under the FEHB Spouse Equity provision as a former spouse
*Workers' Compensation is primary for claims related to your condition under Workers' Compensation.
116 2013 Coventry Health Care Section 9
Section 10. Definitions of terms we use in this brochure
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.
Calendar year
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,
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.
Clinical Trials Cost
Categories
A copayment is a fixed amount of money you pay when you receive covered services.
See section 4.
Copayment
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.
Cost-sharing
Care we provide benefits for, as described in this brochure. Covered services
Coinsurance is the percentage of our allowance that you must pay for your care. You may
also be responsible for additional amounts. See section 4.
Coinsurance
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.
Deductible
Experimental or investigational services includes medical, surgical, diagnostic,
psychiatric, substance abuse or other health care services, technologies, supplies,
treatments, procedures, drug therapies or devices that, at the time the Health Plan makes a
determination regarding coverage in a particular phase, is determined to be:
• Not approved by the U.S. Food and Drug Administration (“FDA”) to be lawfully
marketed for the proposed use and not identified in the
American Hospital Formulary
Service,
the
United States Pharmacopoeia Dispensing Information
, or in the medical
literature as appropriate for the proposed use; or
• Subject to review and approval by the institutional review board of the treating facility
for the proposed use; or
• The subject of a written protocol used by the treating facility for research, clinical
trials or other tests or studies to evaluate its safety, effectiveness, toxicity or efficacy,
as evidenced in the protocol itself or in the written content form used by the treating
facility; or
• Not demonstrated through prevailing peer-reviewed medical literature to be safe and
effective for treating or diagnosing the condition or illness for which its use is
proposed.
The Health Plan, in its judgment, may deem an Experimental Investigational or Unproven
Service a Covered Health Service for treating a life threatening Sickness or condition if it
is determined by the Plan that the Experimental, Investigational or Unproven Service at
the time of the determination:
• Is safe with promising efficacy; and
• Is provided in a clinically controlled research setting; and
Experimental or
investigational service
117 2013 Coventry Health Care Section 10
• Uses a specific research protocol that meets standards equivalent to those defined by
the National Institute of Health.
(For the purpose of this definition, the term “life threatening” is used to describe Sickness
or conditions that are more likely than not to cause death within one year of the date of the
request for treatment.)
This definition does not include Covered Health Services in a Medical Clinical Trial.
A physician or other health care professional licensed, accredited, or certified to perform
specified health services consistent with state law.
Health care professional
Any service or supply for the prevention, diagnosis or treatment which is:
• consistent with Illness, Injury or condition of the Member; and
• according to the approved and generally accepted medical or surgical practice
prevailing in the geographical locality where, and at the time when, the service or
supply is ordered, and for a condition which is treatable and subject to clinical
improvement with active medical intervention. Determination of “generally accepted
practice” and “treatable” is at the discretion of the Medical Director or Designee.
Upon disagreement between a Member and a Participating Physician as to the Medical
Necessity of a particular service, the Medical Director or Designee shall make the
final determination.
Medical necessity
Our Plan allowance is the amount we use to determine our payment and your coinsurance
for covered services. Fee-for-service plans determine their allowances in different ways.
Participating Provider
When services are rendered by a Participating Provider, payment will be made to the
Provider for services rendered, based on the contract we have with the provider.
Non-Participating Provider
When services are rendered by a Non-Participating Provider, we will pay our Out-of-
Network Plan Allowance for covered services. The Out-of-Network Plan Allowance is
the maximum amount covered by Us for approved out-of-network services.
For more information, see
Differences between our allowance and the bill
in Section 4.
Plan allowance
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.
Post-service claims
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.
Pre-service claims
A claim for medical care or treatment is an urgent care claim if waiting 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 judge whether a claim is an urgent care claim by applying the judgement of a prudent
layperson who possesses an average knowledge of health and medicine.
Urgent care claims
118 2013 Coventry Health Care Section 10
If you believe your claim qualifies as an urgent care claim, please contact our Customer
Service Department at (800) 833-7423. You may also prove that your claims is an urgent
care claim by providing evidence that a physician with knowledge of your medical
condition has determined that your claim involves urgent care.
“Us” and “We” refer to Coventry Health Care. Us/We
You refers to the enrollee and each covered family member. You
119 2013 Coventry Health Care Section 10
High Deductible Health Plan (HDHP) Definitions
A deductible is a fixed amount of covered expenses you must incur covered services and
supplies before we start paying benefits for those services. See Section 4.
Calendar year deductible
The maximum you will pay out of pocket before ALL services are covered at 100%. For
the HDHP, the individual catastrophic limit is $4,000 for in-network services. For a
family, the catastrophic limit is $8,000 for in-network services.
Catastrophic limit
120 2013 Coventry Health Care Section 10
Section 11. Other Federal Programs
Please note, the following programs are not part of your FEHB benefits. They are separate Federal programs that
complement your FEHB benefits and can potentially reduce your out-of-pocket expenses. These programs are offered
independent of the FEHB Program and require you to enroll separately with no Government contribution.
First, the Federal Flexible Spending Account Program, also known as FSAFEDS, lets
you set aside pre-tax money from your salary to reimburse you for eligible dependent care
and/or health care expenses. You pay less in taxes so you save money. The result can be a
discount of 20% to more than 40% on services/products you routinely pay for out-of-
pocket.
Second, the Federal Employees Dental and Vision Insurance Program (FEDVIP)
provides comprehensive dental and vision insurance at competitive group rates. There are
several plans from which to choose. Under FEDVIP you may choose self only, self plus
one, or self and family coverage for yourself and any eligible dependents.
Third, the Federal Long Term Care Insurance Program (FLTCIP) can help cover long
term care costs, which are not covered under the FEHB Program.
Important information
about three Federal
programs that
complement the FEHB
program
The Federal Flexible Spending Account Program -
FSAFEDS
It is an account where you contribute money from your salary BEFORE taxes are
withheld, then incur eligible expenses and get reimbursed. You pay less in taxes so you
save money.
Annuitants are not eligible to enroll.
There are three types of FSAs offered by FSAFEDS. Each type has a minimum annual
election of $250. The maximum annual election for a health care flexible spending
account (HCFSA) or a limited expense health care spending account (LEX HCFSA) is
$2,500.
If you are a new or newly eligible employee you have 60 days from your hire date to
enroll in an HCFSA or LEXHCFSA and/or DCFSA, but you must enroll before October 1.
If you are hired or become eligible on or after October 1 you must wait and enroll during
the Federal Benefits Open Season held each fall.
• Health Care FSA (HCFSA) – Reimburses you for eligible health care expenses (such
as copayments, deductibles, insulin, products, physician prescribed over-the-counter
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) which are not covered or reimbursed by FEHBP or FEDVIP coverage or
any other insurance.
FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB
and FEDVIP plans. This means that when you or your provider file 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.
• Limited Expense Health Care FSA (LEX HCFSA) – Designed for employees
enrolled in or covered by a High Deductible Health Plan with a Health Savings
Account. Eligible expenses are limited to dental and vision care expenses for you and
your tax dependents including adult children (through the end of the calendar year in
which they turn 26) which are not covered or reimbursed by FEHBP or FEDVIP
coverage or any other insurance.
What is an FSA?
121 2013 Coventry Health Care Section 11
• Dependent Care FSA (DCFSA) – Reimburses you for eligible non-medical day care
expenses for your child(ren) under age 13 and/or for any person you claim as a
dependent on your Federal Income Tax return who is mentally or physically incapable
of self-care. You (and your spouse if married) must be working, looking for work
(income must be earned during the year), or attending school full-time to be eligible
for a DCFSA.
• If you are a new or newly eligible employee you have 60 days from your hire date to
enroll in an HCFSA or LEX HCFSA and/or DCFSA, but you must enroll before
October 1. If you are hired or become eligible on or after October 1 you must wait
and enroll during the Federal Benefits Open Season held each fall.
• FSAFEDS offers paperless reiumbursement 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 reiumburse your
eligible out-of-pocket expenses based on the claim information it receives from your
plan.
Visit www.FSAFEDS.com or call an FSAFEDS Benefits Counselor toll-free at 1-877-
FSAFEDS (1-877-372-3337), Monday through Friday, 9 a.m. until 9 p.m., Eastern time.
TTY: 1-800-952-0450.
Where can I get more
information about
FSAFEDS?
The Federal Employees Dental and Vision Insurance Program –
FEDVIP
The Federal Employees Dental and Vision Insurance Program (FEDVIP) is separate and
different from the FEHB Program, and was established by the Federal Employee Dental
and Vision Benefits Enhancement Act of 2004. This Program provides comprehensive
dental and vision insurance at competitive group rates with no pre-existing condition
limitations for enrollment.
FEDVIP is available to eligible Federal and Postal Service employees, retirees, and their
eligible family members on an enrollee-pay-all basis. Employee premiums are withheld
from salary on a pre-tax basis.
Important Information
All dental plans provide a comprehensive range of services, including:
• Class A (Basic) services, which include oral examinations, prophylaxis, diagnostic
evaluations, sealants and x-rays.
• Class B (Intermediate) services, which include restorative procedures such as fillings,
prefabricated stainless steel crowns, periodontal scaling, tooth extractions, and denture
adjustments.
• Class C (Major) services, which include endodontic services such as root canals,
periodontal services such as gingivectomy, major restorative services such as crowns,
oral surgery, bridges and prosthodontic services such as complete dentures.
• Class D (Orthodontic) services with up to a 24-month waiting period for dependent
children up to age 19.
Dental Insurance
All vision plans provide comprehensive eye examinations and coverage for lenses, frames
and contact lenses. Other benefits such as discounts on LASIK surgery may also be
available.
Vision Insurance
You can find a comparison of the plans available and their premiums on the OPM website
at www.opm.gov/insure/vision and at www.opm.gov/insure/dental. These sites also
provide links to each plan’s website, where you can view detailed information about
benefits and preferred providers.
Additional Information
You enroll on the Internet at www.BENEFEDS.com. For those without access to a
computer, call 1-877-888-3337, (TTY 1-877- 889-5680).
How do I enroll?
122 2013 Coventry Health Care Section 11
The Federal Long Term Care Insurance Program –
FLTCIP
The Federal Long Term Care Insurance Program (FLTCIP) can help pay for the
potentially high cost of long term care services, which are not covered by FEHB plans.
Long term care is help you receive to perform activities of daily living – such as bathing
or dressing yourself - or supervision you receive because of a severe cognitive impairment
such as Alzheimer's disease. For example, long term care can be received in your home
from a home health aide, in a nursing home, in an assisted living facility or in adult day
care. To qualify for coverage under the FLTCIP, you must apply and pass a medical
screening (called underwriting). Federal and U.S. Postal Service employees and
annuitants, active and retired members of the uniformed services, and qualified relatives,
are eligibe to apply. Certain medical conditions, or combinations of conditions, will
prevent some people from being approved for coverage. You must apply to know if you
will be approved for enrollment. For more information, call 1-800-LTC-FEDS
(1-800-582-3337), (TTY 1-800-843-3557) or visit www.ltcfeds.com.
It's important protection
The Pre-existing Condition Insurance Plan (PCIP)
An individual is eligible to buy coverage if:
• He or she has a pre-existing medical condition or has been denied coverage because of
the health condition;
• He or she has been without health insurance for the last six months. (If the individual
currently has insurance coverage that does not cover the pre-existing condition or is
enrolled in a state high-risk pool then that person is not eligible for PCIP);
• He or she is a citizen or national of the United States or resides in the U.S. legally.
The Federal government administers PCIP in the following states: Alabama, Arizona,
District of Columbia, Delaware, Florida, Georgia, Hawaii, Idaho, Indiana, Kentucky,
Louisiana, Massachusetts, Minnesota, Mississippi, North Dakota, Nebraska, Nevada,
South Carolina, Tennessee, Texas, Vermont, Virginia, West Virginia and Wyoming. To
find out about eligibility, visit www.pcip.gov and/or www.healthcare.gov or call
1-866-717-5826 (TTY): 1-866-561-1604
Do you know someone
who needs health
insurance but can't get
it? The Pre-Existing
Condition Insurance Plan
(PCIP) may help.
123 2013 Coventry Health Care Section 11
Index
Do not rely on this page; it is for your convenience and may not show all pages where the terms appear.
Accidental injury ......33, 40, 57, 78, 83, 100
Allergy tests .........................................31, 76
Ambulance ...............................17, 48, 50, 91
Anesthesia ............................................46, 88
Biopsy ..................................................38, 82
Blood and blood plasma .................47, 89, 90
Casts ........................................46, 47, 89, 90
Catastophic protection (out-of-pocket
maximum) ............................................23, 64
Changes for 2013 .......................................13
Chemotherapy ......................................32, 77
Chiropractic ..........................................36, 80
Cholesterol tests ...................................28, 71
Claims ......................................................106
Coinsurance ................................................22
Colorectal cancer screening .................28, 71
Congenital anomalies ...............38, 40, 82, 83
Contraceptive drugs and devices .........55, 98
Cost-sharing .............................................117
Crutches ...............................................35, 79
Deductible ...........................................11, 22
Definitions ........................................117, 118
Dental care .........................................57, 100
Diagnostic services ..............................28, 74
Dressings ..............................................46, 89
Durable medical equipment .................35, 79
Emergency ..........................................49, 93
Experimental or investigational ...............105
Eyeglasses ..................................................17
Family planning ...........................29, 30, 75
Fecal occult blood test .........................28, 71
Fraud ............................................................3
General exclusions .................................105
Hearing services .................................33, 78
Home health services ...........................36, 80
Hospital ................................................46, 89
Immunizations ....................................29, 72
Infertility ..............................................31, 76
Insulin ............................................28, 47, 89
Magnetic Resonance Imagings (MRIs)
..............................................................12
Mammogram ........................................20, 66
Maternity benefits ................................22, 67
Medicaid ..................................................105
Medically necessary ...10, 19, 30, 38, 41, 43,
45, 49, 65, 66, 73, 80, 83, 85, 87, 91, 96
Medicare ..........................101, 102, 103, 104
Original ..............................................102
Members
Associate ............................................119
Family ................................................119
Plan ................................................15, 54
Mental Health/Substance Abuse Benefits
........................................................51, 94
Licensed Practical Nurse (LPN) ...28, 69,
78, 90
Nurse ...................................................36, 80
Occupational therapy ........................31, 77
Ocular injury ..............................................70
Office visits ............................................6, 18
Oral and maxillofacial surgical ......32, 33, 75
Out-of-pocket expenses .......................23, 64
Overseas claim ...........................................98
Oxygen ................................................28, 72,
Pap test ................................................20, 61
Physician ..............................................27, 74
Precertification ...........................................17
Prescription drugs ................................53, 96
Preventive care, children ......................28, 71
Prior approval .............................................17
Prosthetic devices .................................27, 68
Psychologist .........................................51, 94
Room and board .................................46, 89
Second surgical opinion .....................19, 66
Skilled nursing facility care ...........12, 39, 81
Social worker .......................................43, 85
Speech therapy .....................................31, 77
Splints ..................................................38, 80
Substance abuse .............................12, 43, 85
Surgery .................................................46, 89
Oral ..............................................57, 100
Outpatient .......................................46, 89
Reconstructive ................................46, 89
Temporary Continuation of Coverage
(TCC) ..................................................10
Transplants ...........................................46, 89
Treatment therapies ..............................31, 77
Vision services ....................................34, 78
Wheelchairs ........................................28, 71
Workers Compensation ............................105
X-rays ..................................................28, 74
124 2013 Coventry Health Care Index
Summary of benefits for the High Option of Coventry Health Care - 2013
•Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions,
limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look
inside.
•If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on
your enrollment form.
•We only cover services provided or arranged by Plan physicians, except in emergencies.
•We have no deductible under the High Option plan.
Benefits You pay Page
Medical services provided by physicians:
Office visit copay: $20 primary care; $40
specialist; preventive care services are
covered at 100%
27 Diagnostic and treatment services provided in the office
Services provided by a hospital:
$200 copayment per day up to a maximum of
$600 per admission
46 • Inpatient
$150 per visit to an ambulatory surgical
center; Charges for surgery in an outpatient
department of a hospital covered at 100%
47 • Outpatient
Emergency benefits:
$30 per urgent care visit; $150 per hospital
emergency room visit
50 • In-area
$30 per urgent care visit; $150 per hospital
emergency room visit
50 • Out-of-area
Your cost-sharing responsiblities are no
greater than for other illnesses or conditions
51 Mental health and substance abuse treatment:
Prescription drugs:
$3 for Tier 1A specific generic medications
$15 for Tier 1 medications
$30 for Tier 2 medications
$60 for Tier 3 medications
(to view the listing of tiered medications,
please see our 2013 Rx formulary, at www.
chcde.com)
54 • Retail pharmacy
•
Tier 1A formulary medications.
Tier 1A is a list of
specific generic medications that are available to you
at a reduced copayment. To view and download the
specific list of Tier 1A medications, go to www.chcde.
com, plan members, and select the section entitled
Federal & Postal employees.
$6 for Tier 1A specific generic medications
$30 for Tier 1 medications
$60 for Tier 2 medications
$120 for Tier 3 medications
54 • Mail order (90 day supply)
• Tier 1A formulary medications. Tier 1A is a list of
specific generic medications that are available to you
at a reduced copayment. To view and download the
specific list of Tier 1A medications, go to www.chcde.
com, plan members, and select the section entitled
Federal & Postal employees.
57 Dental care:
125 2013 Coventry Health Care High Option Summary
$20 PCP copayment or $40 Specialist co-
payment; Nothing during a covered inpatient
admission.
Nothing after $1,000/Self Only or $3,000/
Family enrollment per year
Some costs do not count toward this
protection
23 Protection against catastrophic costs (out-of-pocket
maximum):
126 2013 Coventry Health Care High Option Summary
Summary of benefits for the Standard Option of Coventry Health Care - 2013
•Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions,
limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look
inside.
•If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on
your enrollment form.
•We only cover services provided or arranged by Plan physicians, except in emergencies.
•Below, an asterisk (*) means the item is subject to the $300 per individual, $600 per family calendar year deductible.
Standard Option Benefits You Pay Page
Medical services provided by physicians:
$20 PCP copayment or $40 Specialist
copayment; preventive care services are
covered at 100%
27 Diagnostic and treatment services provided in the office
Services provided by a hospital:
$200 per day copay up to a maximum of $600
per admission copay
46 • Inpatient
20% coinsurance* 47 • Outpatient
Emergency benefits:
20% coinsurance* 50 • In-area
20% coinsurance* 50 • Out-of-area
Your cost-sharing responsibilities are no
greater than for other illnesses or conditions
51 Mental health and substance abuse treatment:
Prescription drugs:
$3 for Tier 1A specific generic medications
$15 for Tier 1 medications
$30 for Tier 2 medications
$60 for Tier 3 medications
(to view the listing of tiered medications,
please see our 2013 Rx formulary, at www.
chcde.com)
54 • Retail pharmacy
• Tier 1A formulary medications. Tier 1A is a list of
specific generic medications that are available to you
at a reduced copayment. To view and download the
specific list of Tier 1A medications, go to www.chcde.
com, plan members, and select the section entitled
Federal & Postal employees.
$6 for Tier 1A specific generic medications
$30 for Tier 1 medications
$60 for Tier 2 medications
$120 for Tier 3 medications
(to view the listing of tiered medications,
please see our 2013 Rx formulary, at www.
chcde.com)
54 • Mail order (90 day supply)
• Tier 1A formulary medications. Tier 1A is a list of
specific generic medications that are available to you
at a reduced copayment. To view and download the
specific list of Tier 1A medications, go to www.chcde.
com, plan members, and select the section entitled
Federal & Postal employees.
$20 PCP copayment or $40 Specialist
copayment; Nothing during a covered
inpatient admission.
57 Dental care:
127 2013 Coventry Health Care Standard Option Summary
Standard Option Benefits You Pay Page
Nothing after $3,000/Self Only or $9,000/
Family enrollment per year
Some costs do not count toward this
protection
23 Protection against catastrophic costs (out-of-pocket
maximum):
128 2013 Coventry Health Care Standard Option Summary
Summary of benefits for the HDHP of Coventry Health Care - 2013
Do not rely on this chart alone. All benefits are subject to the definitions, limitations, and exclusions in this brochure. On
this page we summarize specific expenses we cover; for more detail, look inside. If you want to enroll or change your
enrollment in this Plan, be sure to put the correct enrollment code from the cover on your enrollment form.
In 2013 for each month you are eligible for the Health Savings Account (HSA), will deposit $41.67 per month for Self Only
enrollment or $83.34 per month for Self and Family enrollment to your HSA. For the HSA, you may use your HSA or pay
out of pocket to satisfy your calendar year deductible of $2,000 for Self only and $4,000 for Self and Family. Once you
satisfy your calendar year deductible, Traditional medical coverage begins.
For the Health Reimbursement Arrangement (HRA), your health charges are applied to you annual HRA Fund of $500 for
Self Only and $1,000 for Self and Family. Once your HRA is exhausted, you must satisfy your calendar year deductible.
Once your calendar year deductible is satisfied, Traditional medical coverage begins.
Benefits You pay Page
Nothing 71 In-network medical preventive care
Medical services provided by physicians:
In-Network: All of our allowable amounts up
to the deductible amount and nothing
thereafter
Out-of-Network: 30% of our allowance after
the calendar year deductible
74 Treatment for illness or injury provided in the office
Services provided by a hospital:
In-Network: All of our allowabel amounts up
to the deductible amount and nothing
thereafter
Out-of-Network: 30% of our allowance after
the calendar year deductible
89 • Inpatient
In-Network: All of our allowable amounts up
to the deductible amount and nothing
thereafter
Out-of-Network: 30% of our allowance after
the calendar year deductible
90 • Outpatient
Emergency benefits:
$100 copayment after the calendar year
deductible
93 • In-area
$100 copayment after the calendar year
deductible
93 • Out-of-area
Your cost-sharing responsiblities are no
greater than for other illnesses or conditions
94 Mental health and substance abuse treatment:
129 2013 Coventry Health Care HDHP Summary
Benefits You pay Page
Prescription drugs:
$3 for Tier 1A specific generic medications
$15 for Tier 1 medications
$30 for Tier 2 medications
$60 for Tier 3 medications
(to view the listing of tiered medications,
please see our 2013 Rx formulary, at www.
chcde.com)
97 • Retail pharmacy
• Tier 1A formulary medications. Tier 1A is a list of
specific generic medications that are available to you
at a reduced copayment. To view and download the
specific list of Tier 1A medications, go to www.chcde.
com, plan members, and select the section entitled
Federal & Postal employees.
$6 for Tier 1A specific generic medications
$30 for Tier 1 medications
$60 for Tier 2 medications
$120 for Tier 3 medications
(to view the listing of tiered medications,
please see our 2013 Rx formulary, at www.
chcde.com)
97 • Mail order (90 day supply)
• Tier 1A formulary medications. Tier 1A is a list of
specific generic medications that are available to you
at a reduced copayment. To view and download the
specific list of Tier 1A medications, go to www.chcde.
com, plan members, and select the section entitled
Federal & Postal employees.
In-network: nothing after the calendar year
deductible
Out-of-network: 30% of our allowance after
the calendar deductible
100 Dental care:
$4,000 for self only $8,000 for family 64 Protection against catastrophic costs (out-of-network
maximum):
130 2013 Coventry Health Care HDHP Summary
2013 Rate Information for Coventry Health Care-Maryland
Non-Postal rates apply to most non-Postal employees. If you are in a special enrollment category, refer to the
Guide to
Federal Benefits
for that category or contact the agency that maintains your health benefits enrollment.
Postal Category 1 rates apply to career employees covered by the National Postal Mail Handlers Union (NPMHU),
National Association of Letter Carriers (NALC) and Postal Police bargaining units.
Postal Category 2 rates apply to other non-APWU, non-PCES, non-law enforcement Postal Service career employees,
including management employees, and employees covered by the National Rural Letter Carriers’ Association bargaining unit.
Special Guides to Benefits are published for American Postal Workers Union (APWU) employees (see RI 70-2A) including
Material Distribution Center, Operating Services and Information Technology/Accounting Services employees and Nurses;
Postal Service Inspectors and Office of Inspector General (OIG) law enforcement employees (see RI 70-2IN), Postal Career
Executive Service (PCES) employees (see RI 70-2EX), and noncareer employees (see RI 70-8PS).
Career APWU employees hired before May 23, 2011, will have the same rates as the Category 2 rates shown below. In the
Guide to Benefits for APWU Employees (RI 70-2A) this will be referred to as the “Current” rate; otherwise, “New” rates
apply.
For further assistance, Postal Service employees should call:
Human Resources Shared Service Center
1-877-477-3273, option 5
TTY: 1-866-260-7507
Postal rates do not apply to non-career postal employees, postal retirees, or associate members of any postal employee
organization who are not career postal employees. Refer to the applicable
Guide to Federal Benefits
.
Type of
Enrollment
Enrollment
Code
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Gov't
Share
Your
Share
Gov't
Share
Your
Share
Category 1
Your Share
Category 2
Your Share
High Option Self
Only
IG1 $189.68 $63.22 $410.96 $136.99 $41.73 $47.42
High Option Self
and Family
IG2 $424.95 $209.75 $920.73 $454.45 $162.53 $174.34
Standard Option
Self Only
IG4 $170.71 $56.90 $369.87 $123.29 $37.56 $42.68
Standard Option
Self and Family
IG5 $424.95 $144.08 $920.73 $312.17 $96.86 $108.67
HDHP Option
Self Only
GZ1 $164.69 $54.90 $356.84 $118.94 $36.23 $41.17
HDHP Option
Self and Family
GZ2 $372.74 $124.24 $807.59 $269.20 $82.00 $93.18
131 2013 Coventry Health Care
