Cover Page Mailhandler Medical Insurance Reviews (2024)

The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply.
  • The Standard Option calendar year deductible is $350 per person (limited to $700 per Self Plus One or Self and Family enrollment) for services of Network providers and $600 per person (limited to $1,200 per Self Plus One or $1,500 per Self and Family enrollment) for services of Non-Network providers.
  • The Value Plan calendar year deductible is $600 per person (limited to $1,200 per Self Plus One or Self and Family enrollment) for services of Network providers and $900 per person (limited to $1,800 per Self Plus One or Self and Family enrollment) for services of Non-Network providers.

Note: 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. Inpatient hospitalizations must be precertified by the Plan. See Section 5(c) for inpatient hospital benefits.

Network: See Section 5(d), Accidental injury

Non-Network: 30% of the Plan’s allowance and any difference between our allowance and the billed amount

Network: See Section 5(d), Accidental injury

Non-Network: 40% of the Plan’s allowance and any difference between our allowance and the billed amount

See Section 5(b), Oral and maxillofacial surgery

See Section 5(b), Oral and maxillofacial surgery

We have no other dental benefits

Care Management Program

MHBP offers several types of Care Management Programs that assist you with your care coordination for your acute or chronic condition. The program provides education, clinical support, and access to digital support and well-being tools to help you better manage your health.

The Care Management Program offers:

  • One-on-one personalized nurse support
  • Group coaching
  • Digital support
  • Customized health action plans based on your needs and preferences

To start using our digital support tools, log in to your Aetna member website from www.MHBP.com and then go to your health dashboard. New users will need to register first.

We’re committed to giving you all the support you deserve. That’s why we offer digital, nurse support, and group coaching so you can move easily between the services.

We offer several digital health and wellness related programs and resources:

  • Personal health record – organize and store your health history and information, plus get health alerts and notifications.
  • Health assessment – get a custom, step-by-step plan based on questions about your health and habits.
  • Health Decision Support – learn about your healthcare and treatment options.
  • Digital coaching programs – find dynamic health coaching programs that give you personalized support.
  • Health Dashboard – view your health information, and find entry points to health and wellness programs and resources.

Our Care Management Program includes the following list of services. If you would like to contact the Plan for more information about our program or services, please call 800-410-7778. We are available to assist you Monday-Friday from 6:00 a.m. - 5:00 p.m. Mountain Time (MT).

Back & Joint Care

Provides support for members dealing with musculoskeletal (MSK) issues, acute and chronic pain, and either taking opioids or trying to avoid opioids. The program helps you improve your quality of life by helping you manage and reduce your chronic MSK pain, without surgery or drugs. If MHBP identifies that there is an opportunity to help you improve your care, you will be invited to participate. Eligible participants will receive access to exercise therapy, motivational coaching, one-on-one support and education that is tailored to the participant’s specific needs.

Behavioral Health Support

MHBP provides resources and support to help you address mental health or behavioral health conditions like anxiety, depression, substance use disorders, domestic violence and more. Our team will work with you, help you understand your benefits and guide you through the wellness programs we offer. We are here to support you, get you connected with a clinical social worker, psychologist or other behavior health professional to obtain the right treatment, the best services and resources to manage the daily obstacles that may be keeping you from achieving a healthier happy life.

Cancer Support

Provides dedicated proactive support to individuals along their cancer journey. We understand that a cancer diagnosis is life changing and can be overwhelming and we are here to help you. Through our program individuals will better understand their benefits, have the ability to locate the right provider for their specific need and get certain services approved. Individuals will also receive care management support for holistic care, treatment side effects, and medication management.

Compassionate Care

Offers service and support to members or a family member that have a serious illness or face imminent end-of-life decisions. The program provides tools and information to encourage advanced planning for the kind of issues often associated with an advanced illness, such as living wills, advance directives, and tips on how to begin conversations about these issues with loved ones. This program is designed to provide quality of life improvement through timely member and caregiver education.

Healing Better

Provides support and educational resources for total knee or hip replacement surgery. The program gives you the tools and resources you need to prepare for a successful surgery and healthy recovery. It provides you access to benefit information specific to joint services, holistic overview of pain management options, digital, personalized education on recovery resources, mental and physical health tips and more.

Social Work

Is designed to assist you in improving your quality of life by taking steps to help you locate the right resources. Social workers can help connect you with community resources that can provide you services in times of need. Some examples include:

  • Local food pantries
  • Utility or rental assistance programs
  • Home-delivered meal services
  • Support groups
  • Counseling services
  • Federal and state programs

Our social workers are licensed and degreed professionals who work in a variety of settings, including government and non-profit organizations, hospitals, schools and clinics. Social workers also help treat mental, emotional, and behavioral issues in clinical settings .

Transform Diabetes Care

Helps members keep their diabetes and hypertension under control. The program uses medical claims, pharmacy claims, biometric screening data, and lab results to identify opportunities to help members improve their health. Members are provided personal guidance in five areas of focus, medication adherence, taking the right medication, self-monitoring of blood glucose and blood pressure, lifestyle and comorbidity management and recommended screenings, all are based on the member’s specific needs. You do not need to enroll in this program. If MHBP identifies that there is an opportunity to help you improve your care, we will contact you by phone, letter, email, or even in person by a CVS pharmacist, or MinuteClinic provider.

Lifestyle and Condition Coaching Program

Aetna’s Lifestyle and Condition Coaching (LCC) Program, provides you or your covered dependents personalized support that helps you manage existing conditions, learn new habits and stay on their path to better health. Our Health Coach will partner with you to transform your health goals into action. Your Health Coach will provide guidance, support, and resources to help you overcome obstacles that may be keeping you from realizing optimal health. You can talk to a Coach about the following health-related matters:

  • Tobacco Cessation
  • Weight Management
  • Exercise
  • Nutrition
  • Stress Management
  • Pain Management

How does health coaching work?

  • You can talk with your Health Coach over the phone through conveniently scheduled appointments and create a plan that is right for you to meet your health goals. Everything in the program is tailored to you.
  • You can explore ways to make changes in your behavior that will last.
  • You will receive written materials from your Health Coach that can help you decide where you want to go with your health and how to get there.
  • Appointments can range from 20 minutes to 30 minutes at least twice a month. How long and how often you meet with your Health Coach depends on your individual needs.

Aetna’s Lifestyle and Condition Coaching Program also provides pain management/opioid support. The program is designed for members with chronic pain and either taking opioids or trying to avoid opioids. Members enrolled will receive coaching and support, which includes assisting with identifying the availability of other treatment plans that may include non-pharmacologic modalities for the treatment of pain such as, but not limited to: injection therapies, cognitive therapies, psychosocial support, massage therapy, or physical therapy visits as applicable. The program also helps with psychological effects of chronic pain, reduction of opioid use, avoiding opioid use and resources for those who are dependent on opioid medications.

To self-refer or enroll in the program, contact LCC at 866-533-1410 or go to www.myactivehealth.com/MHBP. Our Health Coaches are available Monday through Friday from 8 a.m. – 8 p.m. Eastern Time (ET).

Flexible Benefits Option

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

We may identify medically appropriate alternatives to regular contract benefits and coordinate other benefits as a less costly alternative benefit. 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).

Aetna Member Website

Aetna member website, our secure member self-service website, provides you with the tools and personalized information to help you manage your health. Click on Aetna member website from www.MHBP.com to register and access a secure, personalized view of your benefits.

• Print temporary ID cards

• Download details about a claim such as the amount paid and the member’s responsibility

• Contact member services at your convenience through secure messages

• Access cost and quality information through our transparency tools

• View and update your Personal Health Record

• Find information about the perks that come with your Plan

• Access health information through Healthwise® Knowledgebase

Registration assistance is available toll free, Monday through Friday, from 7am to 9pm Eastern Time at 800-225-3375. Register today at www.MHBP.com.

Wellness fund balance:

To monitor the availability of funds in your Wellness Fund Account, log in to your Aetna member website from www.MHBP.com. Once you log in, select "Discover a Healthier You" under the "Health and Wellness" icon and proceed.

Aetna Health Mobile App

You can use the Aetna Health Mobile app to:

  • Find doctors and facilities using location and see maps for directions
  • Save doctors and facilities to contacts to use text and email
  • Locate urgent care - walk-in clinics, urgent care clinics, emergency rooms
  • View claims and claim details
  • View benefits and balances
  • Track out-of-pocket dollars
  • View ID card information
  • Store ID card offline
  • Save money by using the Cost Estimator to compare cost estimates
  • View your Health History
  • Share your opinion (feedback)

The app can be downloaded for free onto your mobile device

Personal Health Record

The new MHBP Personal Health (PHR) record provides members a dashboard view of their health. Members can view, track and add personal health data and use personalized tools and health information to proactively manage their healthcare.

Access the PHR through the secure member portal at www.MHBP.com.

TeleHealth

MHBP offers access to Teladoc® telemedicine consultations any time, day or night t hat is easy to use, private and secure. Teladoc is the nation’s leading virtual care provider with over 3,600 board certified, state-licensed, primary care providers, pediatricians and specialists that have on average 20 years of experience and are available by web, phone and the Teladoc mobile app. Wit h Teladoc, you can take care of most common issues such as: cold & flu symptoms, allergies, cough, sinus infection, respiratory infection, eye infection, skin problems and more. You can also see a therapist for ongoing counseling for concerns such as: depression, anxiety, stress, as well as for diet and nutrition assistance.

  1. Download the iOS or Android App by searching “Teladoc”
  2. Sign-up on the web at www.teladoc.com
  3. Sign-up by phone, call 855-835-2362 (855-Teladoc)

Note: Teladoc does not replace your primar y care provider. Teladoc does not guarantee that a prescription will be written. Teladoc operates subject to state regulations and may not be available in certain states. Teladoc does not prescribe DEA controlled substances, non-therapeutic drugs and certain other drugs which may be harmful because of their potential for abuse. Teladoc physicians reserve the right to deny care for potential misuse of services.

If you have any questions or would like more information about the program, please call us at 800-410-7778.

SkinIO

SkinIO TM offers a skin cancer detection app to check yourself for skin cancer in just 10 minutes without leaving your home.

  • Download the SkinIO app from the App Store or Google Play Store
  • Activate your account using organization code: SKINCHECK
  • The SkinIO app guides you to take 13 HIPAA-secure photos of your skin plus as many close-ups as you want
  • Your photos are securely encrypted, removed from your phone, and sent to an expert dermatologist for review
  • You’ll get your results by email in 2-3 business days
  • SkinIO will help connect you to expedited in-person care if you need it
  • The Skin Health Navigator Team will reach out to ensure that you're able to download, access, and take full advantage of your SkinIO benefit

Have questions or want help getting started with your skin check? Call the friendly Skin Health Navigator Team at 855-754-6400, they're happy to assist in any way they can.

To sign up for SkinIO please visit: www.bit.ly/MHBPSKIN

Health Risk Assessment

A health risk assessment (HRA) can help individuals identify potential risks to their physical and mental health. The HRA starts with a questionnaire that asks about your nutrition, weight, physical activity, stress, safety and mental health, kind of like an interview. Your responses can lead to suggestions and programs that can help you improve your health by reducing risks. After you complete the questionnaire you'll get a personalized summary that helps you identify and understand potential risks.

MHBP offers a free and confidential HRA online. To take the HRA, log in to your Aetna member website from www.MHBP.com, under Health and Wellness, select Discover A Healthier You and proceed. If you haven't logged in before, you'll need to register for a member account.

If you prefer to complete the HRA by phone, call us at 866-533-1410 to schedule an appointment so a Health Coach can assist you with completing the HRA. You'll get your results by mail and you'll have the opportunity to participate in health coaching programs by phone.

After you complete your HRA, you are eligible for a reward. See Health Risk Assessment reward, below.

Health Risk Assessment reward

After you complete the Health Risk Assessment (HRA), you are eligible to receive a $ 100 (Standard Option) or a $75 ( Value Plan) credit to your Wellness Fund account that can be used for qualified medical expenses, such as your cost sharing amounts for future services.

The reward is available one per calendar year to all members age 18 and older, and can be used by any covered family me mber. If you or a family member leave MHBP, any incentives earned or remaining in your account will be forfeited.

After you have completed the HRA, we will credit your Wellness Fund Account with your incentive reward amount.

If you have any questions or would like more information about the program, please call us at 800-410-7778.

Biometric screening reward

Complete a biometric screening through Quest Diagnostics and receive a Wellness Fund Account incentive reward of $ 100 (Standard Option) or $75 (Value Plan) that can be used for qualified medical expenses, such as your cost sharing a mounts for future services.

The reward is available once per calendar year to all me mbers age 18 and older, and can be used by any covered family member. If you or a family member leave MHBP, any incentives earned or remaining in your account will be forfeited.

You can qualify for your reward in three ways:

  • Make an appointment for your biometric screening at a Quest Diagnostics Patient Service Center (PSC).
  • Have your physician perform the biometric screening as part of your annual check-up, record the results on the Biometric Screening Physician Results form and fax the form to Quest Diagnostics no later than November 30.
  • Or complete your biometric wellness screening using at-home collections materials from Quest Diagnostics.

To register for your screening at a PSC, to order your at-home collections materials or to download your physician form, call 855.6.BE.WELL (855-623-9355) or visit My.QuestforHealth.com and enter the registration key: mhbp

Once your biometric screening is complete, your results will be available online at My.QuestforHealth.com

After you have completed the biometric screening, we will credit your Wellness Fund Account with your incentive reward amount.

If you have any questions or would like more information about the program, please call us at 800-410-7778.

Digital (online) health coaching

Digital coaching programs — These include nine base programs for weight management, smoking cessation, stress management, nutrition, physical activity, cholesterol management, blood pressure, depression management, and sleep improvement. Programs are prioritized based on a member’s health risk assessment to help create a personalized plan for successful behavior change. Members can engage and participate through personalized messaging with tools and resources to help track their progress and stay on the path to wellness.

This provides you secure access to a broad range of your personal health information after you register.

Access the Plan's website tool from your Aetna member website at www.MHBP.com . Select “Discover a Healthier You” under the Health and Wellness icon, then "Dashboard" and finally "Digital Coach”.

AbleTo Program

AbleTo is an 8-week personalized web-based video conferencing treatment support program- designed to address the unique emotional and behavioral health needs of individuals learning to live with conditions such as heart disease, diabetes, cancer, pain management, digestive health, infertility, and respiratory. The program also provides support for behavioral health conditions such as: depression, anxiety and panic, stress, and alcohol/substance abuse. Additionally, the program assists members with life challenges such as post-partum, bereavement, military transitions, and caregiving. Members work with the same therapist and coach each week to set reasonable goals toward healthier lifestyles.

You may obtain more information or enroll in this voluntary program by calling AbleTo at 866-287-1802. To self enroll, go to www.AbleTo.com/Aetna, enter all the required information on the Speak to an AbleTo Specialist landing page, then submit using the “Request a Call” icon. An AbleTo specialist will contact you within 24 hours

Your nurses or clinicians may refer you to AbleTo as they work directly with you and believe you may benefit from the AbleTo support program. If identified, an Engagement Specialist from AbleTo will contact you to introduce the treatment option.

If you have any questions or would like more information about the program, please call us at 800-410-7778.

24-Hour Nurse Line

MHBP offers members 24 hours a day, 7 days a week access to registered nurses experienced in providing information on a variety of health topics. Call us for more information at 800-556-1555. Foreign language translation for non-English speaking members is available and TDD service for the hearing and speech-impaired is provided. Nurses cannot diagnose, prescribe medication, or give medical advice.

Discount drug program

MHBP members can receive a discount on certain drugs prescribed for cosmetic purposes and impotency. You pay 100% of the discounted price at a network retail pharmacy. Call CVS Caremark at 866-623-1441 to determine whether your drug qualifies for a discounted price.

Round-the-clock member support

We provide integrated health benefit services including a national provider network, clinical management services, a national transplant program, and Care Management Program with round-the-clock benefits support, pharmacy network and plan administration.

You can call us toll-free at any time, day or night, except major holidays, to:

  • Initiate the precertification, prior approval or preauthorization process
  • Get assistance in locating network providers
  • Obtain general healthcare information
  • Have your questions about healthcare issues answered

This 24/7 service is a benefit to you, allowing you to be informed about your healthcare options. There is no penalty for not using it. If you have questions about any of the programs, your benefits or would like general health information, call us at 800-410-7778, 24 hours a day, 7 days a week, except major holidays.

AccordantCare Program

If you are managing a chronic, complex or rare condition, AccordantCare provides one-on-one, personalized support that is tailored to your needs. The program gives you access – anytime, day or night – to a nurse and a resource specialist who specialize in your condition. The AccordantCare Program is for patients or parents of children with certain rare or complex medical conditions. This comprehensive patient care program is offered to members with the following conditions:

  • Amyotrophic Lateral Sclerosis (ALS)
  • Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIPD)
  • Crohn’s Disease
  • Cystic Fibrosis
  • Dermatomyositis
  • Epilepsy (Seizures)
  • Gaucher Disease
  • Hemophilia
  • Hereditary Angioedema
  • Human Immunodeficiency (HIV)
  • Multiple Sclerosis (MS)
  • Myasthenia Gravis (MG)
  • Parkinson's Disease (PD)
  • Polymyositis
  • Pulmonary Arterial Hypertension (PAH)
  • Rheumatoid Arthritis (RA)
  • Scleroderma
  • Sickle Cell Disease (SCD)
  • Systematic Lupus Erythematosus (SLE or Lupus)
  • Ulcerative colitis

If you would like more information or find out if you are eligible, call us at 844-923-0807.

Enhanced Maternity Program with family-building support powered by Maven

Our Enhanced Maternity program, provides trusted information and guidance about family planning, maternity support and postpartum care.

With this program, you will also have access to the following resources:

  • Nurses who are trained in obstetrics and high-risk pregnancy conditions.
  • Behavioral health support, including referrals to resources to deal with stress, depression, and anxiety
  • Postpartum depression screening and support
  • Resources and educational materials through our Maternity Support Program
  • Guided medically appropriate genetic counseling and testing
  • Preeclampsia prevention – If you are identified as high-risk, you will receive educational materials about preeclampsia risk factors, and the benefits of aspirin therapy.
  • Fertility advocate to help you throughout your infertility journey, fertility preservation, same-sex conception needs, and more. The advocate will also provide support and guidance during fertility treatment and provide support if you become pregnant. For direct access to a fertility advocate, call 833-415-1709.

No matter where you are on your journey, our nurses and experts are here to support you along the way. Participation in this program is voluntary and available at no cost to you. The participant and their physician or healthcare provider remain in charge of the participant’s treatment plan. If you would like more information or would like to enroll in the Enhanced Maternity Program, call toll-free 855-282-6344 between 8 am and 9 pm ET.

See Wellness Incentives-Maternal Wellness to earn an incentive if you enroll by the 16th week of your pregnancy.

Via the Enhanced Maternity Program, you and your partner also get 24/7 access to Maven’s digital health platform and quality providers via unlimited video appointments, messaging, and classes.

Your Maven membership includes support on Adoption, Surrogacy, fertility, maternity, and postpartum care:

  • A personal Care Advocate who serves as a trusted guide to help you navigate the Maven platform and connect you with providers throughout your journey
  • Unlimited video chat and messaging with doctors, nurses, and coaches across 35+ specialties, including fertility, mental health, Doulas, Sleep coaches, and pediatrics and more
  • Provider-led virtual classes and vetted articles—tailored to your journey
  • Counseling and expert guidance via Maven Adoption and surrogacy Coaches through different adoption and surrogacy pathways and key considerations in the process

You can activate your no-cost membership at www.mavenclinic.com/join/aetnafamily-OP or download the Maven Clinic app.

Wellness Incentives

Healthy actions that make you eligible to earn an incentive will be deposited into a Wellness Incentive Fund account that can be used for qualified medical expenses, such as your cost sharing amounts for future services are:

Controlling Blood Pressure for members with high blood pressure

If you are identified or self-identify as having high blood pressure, we will provide you a form for your provider to complete. On the form, your provider must document two (2) controlled blood pressure readings below 140/90 on separate visits during the current calendar year for you to earn the $50 incentive.

If you are unable to meet this goal, you will receive the incentive if one of the following is completed by December 1st of the calendar year:

  • Lifestyle and Condition Coaching Program (complete four counseling sessions on Tobacco Cessation, Weight Management, Exercise, Nutrition, or Stress Management). You may enroll online at www.myactivehealth.com/MHBP or call LCC at 866-533-1410 to complete your coaching sessions.
  • Dietary and nutritional counseling (obtain three counseling visits, which includes individual and group behavioral counseling) (See Section 5(a) Preventive Care, adult)

Controlling A1C Hemoglobin levels for members with diabetes

If you are identified or self-identify as having diabetes, we will ask you to have your provider submit your A1C laboratory results. Your A1C laboratory results must be less than 8% during the calendar year for you to earn the $50 incentive. If your A1C is greater than or equal to 8%, you will receive the incentive if one of the following is completed by December 1st of the calendar year:

  • Lifestyle and Condition Coaching (LCC) Program (complete four personal coaching or group coaching sessions). You may enroll online at www.myactivehealth.com/MHBP or call LCC at 866-533-1410 to complete your coaching sessions
  • Diabetic Education or Training (see Section 5(a) Educational classes and programs)

Complete any of the following steps to earn a reward:

  • Enroll in our Maternity Program or complete a pregnancy survey by the 16th week of your pregnancy. - $25
  • Send provider documentation of prenatal visit in 1st trimester -$25
  • Complete pre-delivery call between 27-32 weeks with a Care Manager- $25
  • Complete a 4-week postpartum call with a Care Manager -$25

To receive your incentive for any of the above noted healthy actions, you must submit the required documentation by December 31 of the calendar year to the following address:

MHBP
PO Box 981106
El Paso, TX 79998-1106

Members 18 years of age or older who earn financial incentives through participation in the Health Risk Assessment, Biometric Screening and Wellness Incentives Programs will have funds deposited into a Wellness Fund Account. Standard Option members are eligible to earn up to $350 per person per calendar year. Value Plan members are eligible to earn up to $300 per person per calendar year. If you or a family member leave MHBP, any incentives earned or remaining in your account will be forfeited.

Wellness fund account:

To monitor the availability of funds in your Wellness Fund Account, log in to the Aetna member website from www.MHBP.com. Once you log in, select "Discover a Healthier You" under the "Health and Wellness" icon and proceed. If you would like to contact the Plan for more information about the Wellness Incentives Program, please call 800-410-7778, 24 hours a day, 7 days a week, except major holidays.

Aetna Institutes

Aetna Institutes of Excellence (IOE) Transplant Network Program

The Plan participates in the Aetna Institutes of Excellence (IOE) Transplant Network program. The Plan has special arrangements with facilities to provide services for tissue and organ transplants only. The transplant network was designed to give you an opportunity to access providers that demonstrate high quality medical care for transplants. Because transplantation is a highly specialized area, not all Network hospitals are part of the Aetna Institutes of Excellence program. See Section 5(b), Organ/tissue transplants for the Plan’s Organ/Tissue transplants benefit.

  • We cover donor screening and search expenses for up to four (4) candidate donors per transplant occurrence.
  • We cover related medical and hospital expenses of the donor for the initial transplant confinement when we cover the recipient if these expenses are not covered under any other health plan.

Gene-Based, Cellular and Other Innovative Therapies (GCIT TM ) Designated Network Program

The Plan participates in the GCIT Designated Network Program. The Plan has special arrangements with facilities to provide services for members who have been diagnosed with certain genetic conditions. See Section 5(a), Treatment therapies for the Plan’s GCIT benefit.

Travel Benefit

If the Aetna IOE Transplant or GCIT Designated facility needed is more than 100 miles from the patient’s residence, certain Travel & Lodging expenses for the patient and one companion may be reimbursed if pre-authorized by Aetna. Members who use the Aetna IOE Transplant Program or GCIT Designated Network Program, may be approved reasonable travel (air, train, bus and/or taxi), and lodging expenses up to a maximum of $10,000 per transplant for the recipient and one companion. If the transplant recipient is age 21 or younger, we pay up to $10,000 for eligible travel costs for the member and two caregivers. Reimbursement is subject to IRS regulations.

Note: Receipts are required for reimbursement of travel costs.

Note: The Plan must be the primary payor for health benefits to be eligible for the travel benefit.

If you have any questions or would like more information about the program, please call us at 800-410-7778.

The benefits in this Non-FEHB benefits section are not part of the FEHB contract or premium, and you cannot file an FEHB disputed claim about them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection out-of-pocket maximums. These programs are the responsibility of the Plan, and all appeals must follow our guidelines. For additional information contact us at 800-410-7778 or visit our website, www.MHBP.com.

The MHBP Dental and Vision Plans

Two programs are available to ALL Federal and Postal employees and annuitants eligible for FEHBP and their family members. Help plug the gaps in your FEHBP coverage with comprehensive benefits at affordable group rates. They are brought to you by the MHBP, but you do not have to be an MHBP member to get them. A single annual $52 MHBP associate membership fee makes the MHBP Supplemental Dental and Vision Plans available to you.

Enroll in either plan – or both – any time! The sooner you enroll, the sooner your coverage starts!

Get all the details on both plans at www.MHBP.com, and enroll too! Or call toll-free: 800-254-0227.

Hearing Care Solutions offers a wide selection of digital hearing aids from major nationwide providers at the most affordable prices. Additional services are also available to help you save. Call 866-344-7756 or visit www.MHBP.com for more information. One of our representatives will help you find a provider and set up an appointment.

Amplifon Hearing Health Care is one of the largest providers of hearing healthcare benefits in the United States offering members discounts on hearing exams, services and a variety of hearing aids. Call 888-901-0129 , or visit www.AmplifonUSA.com/MHBP and one of our friendly representatives will explain the Amplifon process and assist you in scheduling your appointment with a hearing care provider.

EyeMed Vision Care Program: Save up to 35% with your EyeMed Vision Care discount program. Members are eligible for discounts on exams, glasses and contact lenses at thousands of providers nationwide. Members have access to over 27,000 providers at over 110,00 locations including optometrists, ophthalmologists, opticians and leading optical retailers such as: LensCrafters, Target Optical, participating Pearle Vision locations, and many independent providers. For more information concerning the program or to locate a participating provider, visit the Plan’s website, www.MHBP.com, or call 866-559-5252 .

Laser Vision Correction: EyeMed and LCA-Vision have arranged to provide a discount program to all EyeMed members through one of the largest laser networks available, the US Laser Network. Simply call 800-422-6600 for more information and to find a network provider near you and begin the process.

LifeStation® Medical Alert: MHBP members can receive a discounted rate from LifeStation, a leading provider of medical alert systems. LifeStation offers traditional landline, cellular, mobile and GPS-enabled systems to ensure a solution for every member. Call toll-free at 855-322-5011 or visit www.lifestation.com/mhbp to learn more! about the low monthly rate with no long-term contracts.

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 we determine it is medically necessary to prevent, diagnose, or treat your illness, disease, injury, or condition.

We do not cover the following:

  • 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 in the United States.
  • Experimental or investigational procedures, treatments, drugs or devices.
  • 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 for which there would be no charge if the covered individual had no health insurance coverage.
  • Services, drugs, or supplies related to sexual dysfunction, impotency or sexual inadequacy.
  • Services, drugs, or supplies you receive from a provider or facility barred or precluded from the FEHB Program.
  • Services, drugs, or supplies you receive without charge while in active military service .
  • Services and supplies furnished by yourself, household members or immediate relatives, such as spouse, parents, grandparents, children, brothers or sisters by blood, marriage or adoption.
  • Services, drugs, or supplies ordered or furnished by a non-covered provider.
  • Services and supplies furnished or billed by a non-covered facility, except medically necessary prescription drugs.
  • Services, drugs and supplies associated with care that is not covered.
  • Any portion of a provider’s fee or charge ordinarily due from the enrollee but that has been waived. If a provider routinely waives (does not require the enrollee to pay) a deductible, copayment or coinsurance, the Plan will calculate the actual provider fee or charge by reducing the fee or charge by the amount waived.
  • Charges which the enrollee or Plan has no legal obligation to pay, such as excess charges for an annuitant age 65 or older who is not covered by Medicare Parts A and/or B, doctor’s charges exceeding the amount specified by the Department of Health and Human Services when benefits are payable under Medicare or State premium taxes however applied. See Section 9, Coordinating benefits with Medicare and other coverage.
  • Educational, recreational or milieu therapy, whether in or out of the hospital.
  • Biofeedback.
  • Services and supplies for cosmetic purposes.
  • Travel, even if prescribed by a doctor, except as provided under the Aetna Institutes of Excellence transplant program or Ambulance benefit.
  • “Never Events” are errors in patient care that can and should be prevented. We will follow the policy of the Centers for Medicare and Medicaid Services (CMS). The Plan will not cover care that falls under these policies. For additional information, visit www.CMS.gov, enter Never Events into SEARCH.
  • Services charged by a healthcare provider such as: membership or concierge service fees, handling or administrative charges (medical records or missed appointments), telehealth transmission fees or physician standby services.
  • Services or supplies we are prohibited from covering under the Federal Law.
  • Services and/or supplies not listed as covered.

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.

How to claim benefits

To obtain claim forms, claims filing advice or answers about our benefits, contact us at 800-410-7778 , or visit our website at www.MHBP.com.

In most cases, providers and facilities file claims for you. Your provider must file on the form CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. All claims should be completed in ink or type that is readable by an optic scanner. For claims questions and assistance, call us at 800-410-7778 .

When you must file a claim – such as for services you received overseas or when another group health plan is primary – submit it on the CMS-1500 or a claim form that includes the information shown below. Bills and receipts should be itemized and show:

  • Name of patient and relationship to enrollee;
  • Plan identification number of the enrollee;
  • Name, address and provider or employer tax identification of person or firm providing the service or supply;
  • Dates that services or supplies were furnished;
  • Diagnosis;
  • Type of each service or supply; and
  • The charge for each service or supply.

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

  • If another health plan is your primary payor, you must send a copy of the explanation of benefits (EOB) form you received from your primary payor (such as the Medicare Summary Notice (MSN)) with your claim.
  • Bills for home nursing care must show that the nurse is a registered or licensed practical nurse.
  • Claims for rental or purchase of durable medical equipment; private duty nursing; and physical, occupational, and speech therapy require a written statement from the provider specifying the medical necessity for the service or supply and the length of time needed.

Medical claims

After completing a claim form and attaching proper documentation, send medical claims to:

MHBP Medical Claims
PO Box 981106
El Paso, TX 79998-1106

Prescription drug claims

Claims for covered prescription drugs and supplies that are not ordered through the mail order prescription drug program or not purchased from and electronically filed with a participating CVS Caremark network pharmacy must include receipts that show the prescription number, NDC number (included on the bill), name of drug or supply, prescribing provider's name, date, charge and name and address of the pharmacy.

After completing a claim form and attaching proper documentation send prescription claims to:

CVS Caremark
Attn: Claims Department
PO Box 52136
Phoenix, AZ 58072-2136

Note: Do not include any medical or dental claims with your claims for drug benefits.

If all the required information is not included on the claim, the claim may be delayed or denied.

Post-service claim procedures

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

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

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

Send us all the documents for your claim as soon as possible. We must receive all charges for each 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. Once we pay benefits, there is a three-year limitation on the re-issuance of uncashed checks.

Overseas (foreign) claims

Overseas providers (those outside the continental United States, Alaska and Hawaii) will be paid at the Network level of benefits for covered services. Overseas hospitals and physicians are under no obligation to file claims for you. You may be required to pay for the services at the time you receive them and then submit a claim to us for reimbursement.

  • We will provide translation and currency conversion services for claims for overseas (foreign) services.
  • For inpatient hospital services, the exchange rate will be based on the date of admission. For all other services, we will apply the exchange rate for the date the services were rendered.
  • All foreign claim payments will be made directly to the enrollee except for services rendered to beneficiaries of the United States Department of Defense third party collection program.
  • Canceled checks, cash register receipts, or balance due statements are not acceptable.

Claims that are submitted by the hospital will be paid directly to the hospital (with the exception of foreign claims). You may authorize direct payment to any other provider of care by signing the assignment of benefits section on the claim form, or by using the assignment form furnished by the provider of care. The provider of care’s Tax Identification Number must accompany the claim. The Plan reserves the right to make payment directly to you, and to decline to honor the assignment of payment of any health benefits claim to any person or party.

Claims submitted by Network hospitals and medical providers will be paid directly to the hospital or provider.

Note: Benefits for services provided at Department of Defense, Veterans Administration or Indian Health Service facilities will be paid directly to the facility.

Please reply promptly when we ask for additional information. We may delay processing or deny benefits for your claim if we do not receive the requested information within 60 days. Our deadline for responding to your claim is stayed while we await all of the additional information needed to process your claim.

Authorized representative

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

Notice Requirements

The Secretary of Health and Human Services has identified counties where at least ten percent (10%) of the population is literate only in certain non-English languages. The non-English languages meeting this threshold in certain counties are Spanish, Chinese, Navajo and Tagalog. If you live in one of these counties, we will provide language assistance in the applicable non-English language. You can request a copy of your Explanation of Benefits (EOB) statement, related correspondence, oral language services (such as phone customer assistance), and help with filing claims and appeals (including external reviews) in the applicable non-English language. The English versions of your EOBs and related correspondence will include information in the non-English language about how to access language services in that non-English language.

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

You may appeal directly to the Office of Personnel Management (OPM) if we do not follow required claims processes. For more information or to make an inquiry 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 call MHBP customer service at the phone number found on your enrollment card, plan brochure or plan website www.MHBP.com.

Please follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on your post-service claim (a claim where 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 services, 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 materials 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 to us at MHBP, PO Box 981106, El Paso, TX 79998-1106 or by calling us at 800-410-7778 .

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 healthcare 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 will not take into account the initial decision. The review will not be conducted by the same person, or their subordinate, who made the initial decision.

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.

1

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: MHBP, PO Box 981106, El Paso, TX 79998-1106; 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), if you would like to receive our decision via email. Please note that by giving us your email, we may be able to provide our decision more quickly

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

2

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

a) Pay the claim, or

b) Write to you and maintain our denial, or

c) Ask you or your provider for more information.

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

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

3

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

You must write to OPM within

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

Write to OPM at: United States Office of Personnel Management, Healthcare and Insurance, Federal Employee Insurance Operations, FEHB 2 , 1900 E Street, NW, Washington, DC 20415-3620.

Send OPM the following information:

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

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

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

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

4

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

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

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

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

Note: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call us at 800-410-7778. We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can quickly review your claim on appeal. You may call OPM’s FEHB 2 at 202-606-3818 between 8 a.m. and 5 p.m. Eastern Time.

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

When you have other health 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 healthcare expenses without regard to fault. This is called “double coverage”.

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

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

When we are the secondary payor, we will determine our allowance. After the primary plan processes the benefit, we will pay what is left of our allowance, up to our regular benefit, or up to the member’s responsibility as determined by the primary plan if there is no adverse effect on you (that is, you do not pay any more), whichever is less. We will not pay more than our allowance. The combined payment from both plans may be less than (but will not exceed) the entire amount billed by the provider.

The provision applies whether or not a claim is filed under the other coverage. When applicable, authorization must be given to this Plan to obtain information about benefits or services available from the other coverage, or to recover overpayments from other coverages.

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

TRICARE and CHAMPVA

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

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 or employing o ffice. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next Open Season unless you involuntarily lose coverage under TRICARE or CHAMPVA.

Workers' Compensation

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

We do not cover services that:

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

Medicaid

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

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

When other Government agencies are responsible for your care

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

When others are responsible for injuries

Our reimbursement and subrogation rights are both a condition of, and a limitation on, the benefit payments that you are eligible to receive from us. By accepting Plan benefits, you agree to the terms of this provision.

If you receive (or are entitled to receive) a monetary recovery from any source as the result of an injury or illness, we have the right to be reimbursed out of that recovery for any and all of our benefits paid to diagnose and treat that illness or injury to the full extent of the benefits paid or provided. The Plan's right of reimbursement extends to all benefit payments for related treatment up to and including the date of settlement or judgment, regardless of the date that those expenses were submitted to the Plan for payment. This reimbursement right extends to any monetary recovery that your representatives (for example; heirs, estate) receive (or are entitled to receive) from any source as a result of an accidental injury or illness. This is known as our reimbursement right.

The Plan may also, at its option, pursue recovery as successor to the rights of the enrollee or any covered family member who suffered an illness or injury, which includes the right to file suit and make claims in your name, and to obtain reimbursement directly from the responsible party, liability insurer, first party insurer, or benefit program. This is known as our subrogation right.

Examples of situations to which our reimbursement and subrogation rights apply include, but are not limited to, when you become ill or are injured due to (1) an accident on the premises owned by a third party, (2) a motor vehicle accident, (3) a slip and fall, (4) an accident at work, (5) medical malpractice, or (6) a defective product.

Our reimbursement and subrogation rights extend to all benefits available to you under any law or under any type of insurance or benefit program, including but not limited to:

  • Third party liability coverage
  • Personal or business umbrella coverage
  • Uninsured and underinsured motorist coverage
  • Workers’ Compensation benefits
  • Medical reimbursement or payment coverage
  • Homeowners or property insurance
  • Payments directly from the responsible party
  • Funds or accounts established through settlement or judgment to compensate injured parties
  • No-fault insurance and other insurance that pays without regard to fault, including personal injury protection benefits, regardless of any election made by you to treat those benefits as secondary to us. When you are entitled to the payment of healthcare expenses under automobile insurance, including no-fault insurance and other insurance that pays without regard to fault, your automobile insurance is the primary payor and we are the secondary payor.

Our reimbursement right applies even if the monetary recovery may not compensate you fully for all of the damages resulting from the injuries or illness. In other words, we are entitled to be reimbursed for those benefit payments even if you are not “made whole” for all of your damages by the compensation you receive.

Our right of reimbursement is not subject to reduction for attorney’s fees under the “common fund” or any other doctrine. We are entitled to be reimbursed for 100% of the benefits we paid on account of the injuries or illness unless we agree in writing to accept a lesser amount.

We enforce this right of reimbursement by asserting a first priority lien against any and all recoveries you receive by court order or out-of-court settlement, insurance or benefit program claims, or otherwise, regardless of whether medical benefits are specifically designated in the recovery and without regard to how it is characterized (for example as “pain and suffering”), designated, or apportioned. Our subrogation or reimbursement interest shall be paid from the recovery you receive before any of the rights of any other parties are paid.

You agree to cooperate with our enforcement of our right of reimbursement by:

  • telling us promptly whenever you have filed a claim for compensation resulting from an accidental injury or illness and responding to our questionnaires;
  • pursuing recovery of our benefit payments from the third party or available insurance company;
  • accepting our lien for the full amount of our benefit payments;
  • signing our Reimbursement Agreement when requested to do so;
  • agreeing to assign any proceeds or rights to proceeds from third party claims or any insurance to us;
  • keeping us advised of the claim’s status;
  • agreeing and authorizing us to communicate directly with any relevant insurance carrier regarding the claim related to your injury or illness;
  • advising us of any recoveries you obtain, whether by insurance claim, settlement or court order, and;
  • agreeing that you or your legal representative will hold any funds from settlement or judgment in trust until you have verified our lien amount, and reimbursed us out of any recovery received to the full extent of our reimbursement right.

We also expect you to fully cooperate with us in the event we exercise our subrogation right.

Failure to cooperate with these obligations may result in the temporary suspension of your benefits and/or offsetting of future benefits.

For more information about this process, please call our Third Party Recovery Services unit at 202-683-9140 or 855-661-7973 (toll free). You also can email them at info@estprs.com.

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

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

Clinical trials

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial that is conducted in relation to the prevention, detection, or treatment of cancer or other life-threatening disease or condition, and is either Federally-funded; conducted under an investigational new drug application reviewed by the Food and Drug Administration (FDA); 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 benefits for related care as follows, if it is not provided by the clinical trial:

  • Routine care costs – costs for routine services such as doctor visits, lab tests, X-rays and scans, and hospitalizations related to treating the patient’s condition, whether the patient is in a clinical trial or is receiving standard therapy. These costs are covered by this Plan.
  • Extra care costs – 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.

When you have Medicare

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

Please refer to page (Applies to printed brochure only) for information about how we provide benefits when you are age 65 or older and do not have Medicare.

The Original Medicare Plan (Part A or Part B)

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

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

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

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

  • When we are the primary payor, we process the claim first.
  • When Original Medicare is the primary payor, Medicare processes your claim first. In most cases, your claim will be coordinated automatically and we will then provide secondary benefits for covered charges. To find out if you need to do something to file your claim, call us at 800-410-7778 or see our website at www.MHBP.com.

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

  • When Medicare Part A is primary, we will waive applicable per-admission copayments and coinsurance for inpatient hospital benefits, inpatient mental health/substance use disorder benefits and nursing benefits.
  • When Medicare Part B is primary, we will waive applicable deductibles, copayments and coinsurance for surgical and medical services billed by physicians, durable medical equipment, orthopedic and prosthetic appliances, ambulance services and outpatient mental health/substance use disorder services.

Note: We will not waive the copayments and coinsurance for prescription drugs.

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

Benefit Description: Deductible
Standard Option: You pay without Medicare: In Network: 350/700
Standard Option: You pay without Medicare: Out-of-Network: 600/1,200/1,500
Standard Option: You pay with Medicare Part A & B: N/A
Standard Option: You pay with Medicare Part A & B: N/A

Benefit Description: Catastrophic Protection Out-of-pocket maximum
St andard Option: You pay without Medicare: In Network: 6,000/12,000
Standard Option: You pay without Medicare: Out-of-Network: 9,000/18,000
Standard Option: You pay with Medicare Part A & B: In Network: 6,000/12,000
Standard Option: You pay with Medicare Part A & B: Out-of-Network: 9,000/18,000

Benefit Description: Part B premium reimbursement offered
Standard Option: You pay without Medicare: In Network: N/A
Standard Option: You pay without Medicare: Out-of-Network: N/A
Standard Option: You pay with Medicare Part A & B: In Network: N/A
Standard Option: You pay with Medicare Part A & B: Out-of-Network: N/A

Benefit Description: Primary care provider
Standard Option: You pay without Medicare: In Network: $20 copay
Standard Option: You pay without Medicare: Out-of-Network: 30% of Plan allowance and any difference after deductible
Standard Option: You pay with Medicare Part A & B: In Network: Nothing
Standard Option: You pay with Medicare Part A & B: Out-of-Network: Nothing

Benefit Description: Specialist
Standard Option: You pay without Medicare: In Network: $30 copay
Standard Option: You pay without Medicare: Out-of-Network: 30% of Plan allowance and any difference after deductible
Standard Option: You pay with Medicare Part A & B: In Network: Nothing
Standard Option: You Standard pay with Medicare Part A & B: Out-of-Network: Nothing

Benefit Description: Inpatient hospital
Standard Option: You pay without Medicare: In Network: $200 copayment per admission
Standard Option: You pay without Medicare: Out-of-Network: $500 copay per admission and any difference after deductible
Standard Option: You pay with Medicare Part A & B: In Network: Nothing
Standard Option: You pay with Medicare Part A & B: Out-of-Network: Nothing

Benefit Description: Outpatient hospital
Standard Option: You pay without Medicare: In Network: 10% of Plan allowance after calendar year deductible
Standard Option: You pay without Medicare: Out-of-Network: 30% of Plan allowance and any difference after deductible
Standard Option: You pay with Medicare Part A & B: In Network: Nothing
Standard Option: You pay with Medicare Part A & B: Out-of-Network: Nothing

Benefit Description: Incentives offered
Standard Option: You pay without Medicare: In Network: N/A
Standard Option: You pay without Medicare: Out-of-Network: N/A
Standard Option: You pay with Medicare Part A & B: In Network: N/A
Standard Option: You pay with Medicare Part A & B: Out-of-Network: N/A

  • We will not waive any deductibles, copayments or coinsurance when you have Medicare Part A and/or B as your primary payor.

Call us at 800-410-7778 or visit our website at www.MHBP.com/member-resources/medicare-coordination for more information about how we coordinate benefits with Medicare.

Tell us about your Medicare coverage

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. 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.

Private contract with your physician

If you are enrolled in Medicare Part B, a physician may ask you to sign a private contract agreeing that you can be billed directly for services ordinarily covered by Original Medicare. Should you sign an agreement, Medicare will not pay any portion of the charges, and we will not increase our payment. We will still limit our payment to the amount we would have paid after Original Medicare’s payment. You may be responsible for paying the difference between the billed amount and the amount we paid. We will not waive any deductibles, coinsurance or copayments when paying these claims.

Medicare Advantage (Part C)

If you are eligible for Medicare, you may choose to enroll in and get your Medicare benefits from a Medicare Advantage plan. These are private healthcare choices (like HMOs and regional PPOs) in some areas of the country. To learn more about enrolling in a Medicare Advantage plan, contact Medicare at 800-MEDICARE 800-633-4227, TTY: 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: You may enroll in MHBP Standard Option and our national Aetna Medicare Advantage for MHBP Standard Option if you are an annuitant or former spouse with primary Medicare Parts A and B. Enrollment in the Aetna Medicare Advantage for MHBP Standard Option is voluntary. Our Medicare Advantage plan will enhance your FEHB coverage by lowering/eliminating cost-sharing for services and/or adding benefits at no additional cost. Aetna Medicare Advantage for MHBP Standard Option is subject to Medicare rules. You can enroll in our Medicare Advantage plan with no additional premium. If you are already enrolled and would like to understand your additional benefits in more detail, please call us at 866-241-0262, 8 a.m. to 5:30 p.m., Monday through Thursday or 8:30 a.m. to 5:30 p.m. on Fridays (Eastern Time), go to www.aetnaretireehealth.com/mhbp, or you may also refer to your Medicare plan’s Evidence of Coverage. Once you enroll in our Aetna Medicare Advantage for MHBP Standard Option, we will send you additional information.

When you are enrolled in the MHBP Standard Option under the FEHB Program and Aetna Medicare Advantage for MHBP Standard Option, you receive the following enhanced benefits. Please note that Aetna Medicare Advantage features may vary by location or region.

  • No deductible
  • No copays or coinsurance for covered services (office visits or telehealth, preventive care, surgical care, inpatient/outpatient hospital care, emergency room/urgent care, etc.)
  • Catastrophic Protection Out-of-Pocket Ma ximum of $2,000 per person annually
  • Prescription drug copay or coinsurance per 30-day supply - Generic copays of $0 Preferred Pharmacies, $2 Standard Pharmacies, $5 all other pharmacies; Preferred Brand $35; Non-Preferred Brand $40; and Specialty 15% coinsurance up to $200 maximum
  • Additional benefits such as non-emergency transportation, SilverSneakers® (a registered trademark of Tivity Health Inc.), Resources for Living, meal benefit delivery program following inpatient hospitalization, etc.

Part B Premium Reduction

We will reduce the Part B premium that you pay to the Social Security Administration by $75 per month. If you pay your Part B premium on a monthly basis, you will see this dollar amount credited in your Social Security check. If you pay your Part B premium quarterly, you will see an amount equaling three months of reductions credited on your quarterly Part B premium statement. It may take a few months to see these reductions credited to either your Social Security check or premium statement, but you will be reimbursed for any credits you did not receive during this waiting period.

The Medicare Income-Related Monthly Adjustment Amount (IRMAA) is an amount you pay in addition to your Part B and D premium if your income is above a certain level. Social Security makes this determination based on your income. For additional information concerning the IRMAA, contact the Social Security Administration.

Important Information about your enrollment in our Aetna Medicare Advantage plan for MHBP Standard Option

Aetna Medicare Advantage for Aetna Medicare Advantage for MHBP Standard Option is a Medicare contract separate from the FEHB MHBP Standard Option and depends on contract renewal with CMS. Contact us for a copy of the Evidence of Coverage for the Aetna Medicare Advantage for MHBP Standard Option. You may also obtain a copy of the Evidence of Coverage at the following link www.mhbp.com/retiree. The Evidence of Coverage contains a complete description of plan benefits, exclusions, limitations and conditions of coverage under Medicare Advantage for MHBP Standard Option.

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

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

Medicare prescription drug coverage (Part D)

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.

Individual Medicare Part D coverage: If you are currently enrolled in an individual Medicare Part D plan, your auto-enrollment into the SilverScript PDP for MHBP will result in your disenrollment from that plan. You cannot be covered under two Part D plans at the same time. If you elect to opt out of the SilverScript PDP for MHBP and remain in your individual Medicare Part D plan, your FEHB prescription drug coverage will be secondary to your individual Medicare Part D Plan. In that circumstance, the Plan will supplement the coverage you get under your Medicare Part D prescription drug plan. We will not waive any copayments or coinsurance when you have Medicare Part D as your primary payor. To maximize your benefits, use a pharmacy that is in both the Medicare Part D plan’s network, and in our network. Provide both your Medicare Part D and MHBP ID cards when filling a prescription allowing the pharmacy to coordinate coverage on your behalf.

If you are enrolled in Medicare, and are not enrolled in a Medicare Advantage Plan (Part C) or our our Aetna Medicare Advantage Plan for MHBP Standard Option, you will be automatically enrolled in the Medicare Prescription Drug Plan (PDP) Employer Group Waiver Plan (EGWP). The PDP EGWP is a prescription drug benefit for FEHB covered annuitants and their FEHB covered family members who are eligible for Medicare. This allows you to receive benefits that will never be less than your coverage that is available to members with only FEHB but more often you will receive benefits that are better than members with only FEHB.

This Plan and our PDP EGWP: You will be automatically enrolled in our PDP EGWP and continue to remain enrolled in our FEHB Plan. Participation in the PDP EGWP is voluntary, and you have the choice to opt out of this enrollment at any time.

In the case of those with higher incomes you may have a separate premium payment for your PDP EGWP benefit. Please refer to the Part D- Income-Related Monthly Adjustment Amount (IRMAA) section of the Medicare website: www.medicare.gov/drug-coverage-part-d/costs-for-medicare-drug-coverage/monthly-premium-for-drug-plans to see if you would be subject to an additional premium.

We offer a SilverScript Employer Prescription Drug Plan (PDP) for MHBP, a Medicare Employer Group Waiver Plan (EGWP), to Medicare-eligible annuitants and Medicare eligible family members covered under the Plan. The PDP is a Medicare Part D plan and the copays/coinsurance are equal to or better than the MHBP Standard Option or Value Plan prescription drug benefits, which means you will pay less for prescription drugs than Standard Option and Value Plan members without Medicare Part D coverage. You will generally receive better benefits than members with only FEHB coverage. Covered drugs will be subject to the formulary approved by the Centers for Medicare and Medicaid Services.

If you are an annuitant or an annuitant’s family member who is enrolled in either Medicare Part A or B or Parts A and B, you will be automatically enrolled in SilverScript effective January 1, 2024, or later upon becoming Medicare-eligible. There is no need for you or your eligible dependent to take action to enroll. If you do not wish to enroll in the SilverScript Employer PDP, you may “opt out” of the enrollment by following the instructions mailed to you or by calling us at 833-825-6755. Declining coverage or “opting out” will place you back into your FEHB prescription drug coverage. You can opt out at any time.

Participants who enroll in SilverScript Employer PDP for MHBP will receive a separate SilverScript prescription ID card to use for filling prescriptions. The following are your enhanced prescription benefits:

  • No deductible
  • Catastrophic Protection Out-of-Pocket Maximum of $2,000 per person annually (included in the Plan’s integrated medical and prescription drug overall out of pocket maximum.)
  • Standard Option 30-day prescription supplies:
    • Generic - $5 copay
    • Preferred brand - $45 copay
    • Non-Preferred brand - $60 copay
    • Specialty - 15% of the Plan's allowance; limited to $225 maximum
    • Generic - $10 copay
    • Preferred brand - $55 copay
    • Non-Preferred brand - $80 copay
    • Specialty - 15% of the Plan's allowance; limited to $425 maximum
    • Generic - $10 copay
    • Preferred brand - $47 copay
    • Non-Preferred brand - $100 copay
    • Specialty - 33% of the Plan's allowance; limited to $250 maximum
    • Generic - $20 copay
    • Preferred brand - $140 copay
    • Non-Preferred brand - $250 copay
    • Specialty - 33% of the Plan's allowance; limited to $400 maximum
    C. When either you or a covered family member are eligible for Medicare solely due to disability and you. The primary payor for the individual with Medicare is MedicareThe primary payor for the individual with Medicare is this Plan
    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.

    When you are age 65 or over and do not have Medicare

    Under the FEHB law, we must limit our payments for inpatient hospital care and physician care to those payments you would be entitled to if you had Medicare. Your physician and hospital must follow Medicare rules and cannot bill you for more than they could bill you if you had Medicare. You and the FEHB benefit from these payment limits. Outpatient hospital and non-physician based care are not covered by this law; regular Plan benefits apply. The following has more information about the limits.

    ____________________________________________________________________________________________________

    If you:

    • are age 65 or over, and
    • do not have Medicare Part A, Part B, or both; and
    • have this Plan as an annuitant or as a former spouse, or as a family member of an annuitant or former spouse; and
    • are not employed in a position that gives FEHB coverage. (Your employing office can tell you if this applies.

    ____________________________________________________________________________________________________

    Then, for your inpatient hospital care:

    • The law requires us to base our payment on an amount - the "equivalent Medicare amount" - set by Medicare’s rules for what Medicare would pay, not on the actual charge.
    • You are responsible for your applicable deductibles, coinsurance, or copayments under this Plan.
    • You are not responsible for any charges greater than the equivalent Medicare amount; we will show that amount on the explanation of benefits (EOB) form that we send you.
    • The law prohibits a hospital from collecting more than the "equivalent Medicare amount".

    ____________________________________________________________________________________________________

    And, for your physician care, the law requires us to base our payment and your coinsurance or copayment on

    • an amount set by Medicare and called the "Medicare approved amount," or
    • the actual charge if it is lower than the Medicare approved amount.

    If your physician participates with Medicare or accepts Medicare assignment for the claim and is a member of our Network, then you are responsible for your deductibles, coinsurance, and copayments.

    If your physician participates with Medicare and is not in our Network, then you are responsible for your deductibles, coinsurance, copayments, and any balance up to the Medicare approved amount.

    If your physician does not participate with Medicare, then you are responsible for your deductibles, coinsurance, copayments, and any balance up to 115% of the Medicare approved amount.

    If your physician does not participate with Medicare and is not a member of our Network, then you are responsible for your non-network deductibles, coinsurance, and any balance up to 115% of the Medicare approved amount.

    If your physician opts-out of Medicare via private contract, then you are responsible for your deductibles, coinsurance, copayments, and any balance your physician charges

    It is generally to your financial advantage to use a physician who participates with Medicare. Such physicians are permitted to collect only up to the Medicare approved amount.

    Physicians Who Opt-Out of Medicare

    A physician may have opted-out for Medicare and may or may not ask you to sign a private contract agreeing that you can be billed directly for services ordinarily covered by Original Medicare. This is different than a non-participating doctor, and we recommend you ask your physician if they have opted–out of Medicare. Should you visit an opt-out physician, the physician will not be limited to 115% of the Medicare approved amount. You may be responsible for paying the difference between the billed amount and our regular network/non-network benefits.

    Our explanation of benefits (EOB) form will tell you how much the physician or hospital can collect from you. If your physician or hospital tries to collect more than allowed by law, ask the physician or hospital to reduce the charges. If you have paid more than allowed, ask for a refund. If you need further assistance, call us at 800-410-7778.

    When you have the Original Medicare Plan (Part A, Part B, or both)

    We limit our payment to an amount that supplements the benefits that Medicare would pay under Medicare Part A (Hospital insurance) and Medicare Part B (Medical insurance), regardless of whether Medicare pays. Note: We pay our regular benefits for emergency services to an institutional provider, such as a hospital, that does not participate with Medicare and is not reimbursed by Medicare.

    We use the Department of Veterans Affairs (VA) Medicare-equivalent Remittance Advice (MRA) when the statement is submitted to determine our payment for covered services provided to you if Medicare is Primary, when Medicare does not pay the VA facility.

    When you are covered by Medicare Part B and it is primary, your out-of-pocket costs for services that both Medicare Part B and we cover depend on whether your physician accepts Medicare assignment for the claim.

    • If your physician accepts Medicare assignment, you pay nothing for services that both Medicare and we cover.
    • If your physician does not accept Medicare assignment, you pay the difference between Medicare’s “limiting charge” or the physician’s actual charge (whichever is less) and our payment combined with Medicare’s payment.

    It is important to know that a physician who does not accept Medicare assignment may not bill you for more than 115% of the amount Medicare bases its payment on, called the “limiting charge.” The Medicare Summary Notice (MSN) that Medicare will send you will have more information about the limiting charge. If your physician tries to collect more than allowed by law, ask the physician to reduce the charges. If the physician does not, report the physician to the Medicare carrier that sent you the MSN form. Call us if you need further assistance.

    Please refer to The Original Medicare Plan (Part A or Part B) for more information about how we coordinate benefits with Medicare.

    A bodily injury sustained through external and accidental means, such as broken bones, animal bites, poisonings and injuries to sound natural teeth. Masticating (chewing) incidents are not considered to be accidental injuries.

    The period from entry (admission) into a hospital or other covered facility until discharge. In counting days of inpatient care, the date of entry and the date of discharge are counted as the same day.

    Assignment

    An authorization by you (the enrollee or covered family member) that is approved by us (the Carrier), for us to issue payment of benefits directly to the provider.

    • We reserve the right to pay you directly for all covered services. Benefits payable under the contract are not assignable by you to any person without express written approval from us, and in the absence of such approval, any assignment shall be void.
    • Your specific written consent for a designated authorized representative to act on your behalf to request reconsideration of a claim decision (or, for an urgent care claim, for a representative to act on your behalf without designation) does not constitute an Assignment.
    • OPM’s contract with us, based on federal statute and regulation, gives you a right to seek judicial review of OPM's final action on the denial of a health benefits claim but it does not provide you with authority to assign your right to file such a lawsuit to any other person or entity. Any agreement you enter into with another person or entity (such as a provider, or other individual or entity) authorizing that person or entity to bring a lawsuit against OPM, whether or not acting on your behalf, does not constitute an Assignment, is not a valid authorization under this contract, and is void.

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

    Cardiac rehabilitation

    A comprehensive exercise, education, and behavioral modification program designed to improve the physical and emotional conditions of patients with heart disease. There are four phases of cardiac rehabilitation:

    • Phase I begins in the hospital (inpatient) after experiencing a heart attack or other major heart event. During this phase, individuals receive a visit by a member of the cardiac rehabilitation team who provides education about their disease, recovery, personal encouragement, and nutritional counseling to prepare them for discharge.
    • Phase II begins after leaving the hospital. As described by the U.S. Public Health Service, it is a comprehensive, long-term program that includes medical evaluation, prescribed exercise, cardiac risk factor modification, education and counseling. Phase II refers to constant medically supervised programs that typically begin one to three weeks after discharge and provide appropriate electrocardiographic monitoring. Phase 2 may last 3 to 6 months.
    • Phase III utilizes a supervised program that encourages exercise and healthy lifestyle and is usually performed at home or in a fitness center with the goal of continuing the risk factor modification and exercise program learned in phase II.
    • Phase IV is based on an indefinite exercise program. These programs encourage a commitment to regular exercise and healthy habits for risk factor modification, such as tobacco cessation, stress reduction, nutrition and weight loss, to establish lifelong cardiovascular fitness. Some programs combine phases III and IV.

    Clinical trials cost categories

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

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

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

    Coinsurance

    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.

    A condition existing at or from birth which is a significant deviation from the common form or norm. For purposes of this Plan, congenital anomalies include protruding ear deformities, cleft lips, cleft palates, birthmarks, webbed fingers or toes, and other conditions that the Plan may determine to be congenital anomalies. In no event will the term congenital anomaly include conditions relating to teeth or intraoral structures supporting the teeth.

    Copayment

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

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

    The Plan determines what services are custodial in nature. Custodial care that lasts 90 days or more is sometimes known as Long term care. For instance, the following are considered custodial services:

    • Help in walking; getting in and out of bed; bathing; eating (including help with tube feeding or gastrostomy) exercising and dressing;
    • Homemaking services such as making meals or special diets;
    • Moving the patient;
    • Acting as companion or sitter;
    • Supervising medication when it can be self-administered; or·
    • Services that anyone with minimal instruction can do, such as taking a temperature, recording pulse, respiration or administration and monitoring of feeding systems.

    Deductible

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

    A drug, device, or biological product is experimental or investigational if the drug, device, or biological product cannot be lawfully marketed without approval of the U.S. Food and Drug Administration (FDA) and approval for marketing has not been given at the time it is furnished. Approval means all forms of acceptance by the FDA.

    A medical treatment or procedure, or a drug, device, or biological product is experimental or investigational if 1) reliable evidence shows that it is the subject of ongoing phase I, II, or III clinical trial or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis; or 2) reliable evidence shows that the consensus of opinion among experts regarding the drug, device, or biological product or medical treatment or procedure is that further studies or clinical trials are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with the standard means of treatment or diagnosis.

    Reliable evidence shall mean only published reports and articles in the authoritative medical and scientific literature; the written protocol or protocols used by the treating facility or the protocol(s) of another facility studying substantially the same drug, device, biological product, or medical treatment or procedure; or the written informed consent used by the treating facility or by another facility studying substantially the same drug, device, biological product, or medical treatment or procedure.

    If you wish additional information concerning the experimental/investigational determination process, please contact the Plan.

    Group health coverage

    Healthcare coverage that a member is eligible for because of employment, by membership in, or connection with, a particular organization or group that provides payment for hospital, medical, or other healthcare services or supplies, or that pays a specific amount for each day or period of hospitalization if the specified amount exceeds $200 per day, including extension of any of these benefits through COBRA.

    Healthcare professional

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

    A formal program directed by a doctor to help care for a terminally ill person. The services may be provided through either a centrally-administered, medically-directed, and nurse-coordinated program that provides primarily home care services 24 hours a day, seven days a week by a hospice team that reduces or abates mental and physical distress and meets the special stresses of a terminal illness, dying and bereavement, or through confinement in a hospice care program. The hospice team must include a doctor and a nurse (R.N.) and also may include a social worker, clergyman/counselor, volunteer, clinical psychologist, physical therapist, or occupational therapist.

    An expense is incurred on the date a service or supply is rendered or received unless otherwise noted in this brochure.

    Infertility

    Infertility is disease or medical condition defined as when a person if unable to conceive or produce conception after 1 year of regular sexual intercourse when the individual attempting conception is under 35 years of age, or after 6 months of regular sexual intercourse when the individual attempting conception is 35 years of age or older. Alternatively, infertility can be established by regular sperm insemination(s) (intrauterine, intracervical, or intravaginal), either with or without ovulation induction medication, when the individual attempting conception is under 35 years of age or regular sperm insemination(s) when the individual attempting conception is 35 years of age or older. This definition applies to all individuals regardless of sexual orientation or the presence/availability of a partner. Infertility may also be established by the demonstration of a disease of the reproductive tract such that regular egg-sperm contact would be ineffective.

    See our medical clinical policy bulletin under Section 10, Definitions of Terms We Use in This Brochure - Medical Necessity definition for additional details on Aetna’s Infertility Clinical Policy.

    Inpatient care is rendered to a person who has been admitted to a hospital for bed occupancy for purposes of receiving inpatient hospital services. Generally, a patient is considered an inpatient if formally admitted as inpatient with the expectation that the patient will remain at least overnight and occupy a bed. The hospital bills for inpatient room and board charges for each day (24 hour period) of the inpatient confinement as well as for hospital incidental services. Inpatient hospital benefits apply to services provided by the hospital during an inpatient admission.

    Intensive outpatient treatment

    Intensive outpatient treatment programs must be licensed to provide mental health and/or substance use treatment. Services must be provided for at least two hours per day and may include group, individual, and family therapy along with psychoeducational services and adjunctive psychiatric medication management.

    The sudden and unexpected onset of a condition requiring immediate medical care. The severity of the condition, as revealed by the doctor’s diagnosis, must be such as would normally require emergency care. Medical emergencies include heart attacks, cardiovascular accidents, loss of consciousness or respiration, convulsions and such other acute conditions as may be determined by the Plan to be medical emergencies.

    Medical foods

    The term medical food, as defined in Section 5(b) of the Orphan Drug Act (21 U.S.C. 360ee (b) (3)) is “a food which is formulated to be consumed or administered enterally under the supervision of a physician and which is intended for the specific dietary management of a disease or condition for which distinctive nutritional requirements, based on recognized scientific principles, are established by medical evaluation.” In general, to be considered a medical food, a product must, at a minimum, meet the following criteria: the product must be a food for oral or tube feeding; the product must be labeled for the dietary management of a specific medical disorder, disease, or condition for which there are distinctive nutritional requirements; and the product must be intended to be used under medical supervision.

    Medical necessity

    Services, drugs, supplies, or equipment provided by a hospital or covered provider of healthcare services that the Plan determines are appropriate to diagnose or treat your condition, illness, or injury and that:

    1. are consistent with standards of good medical practice in the United States;
    2. are clinically appropriate, in terms of type, frequency, extent, site, and duration; and considered effective for the patient’s illness, injury, disease, or its symptoms;
    3. are not primarily for the personal comfort or convenience of the patient, the family, or the provider;
    4. are not a part of or associated with the scholastic education or vocational training of the patient; and
    5. in the case of inpatient care, cannot be provided safely on an outpatient basis.

    The fact that a covered provider has prescribed, recommended, or approved a service, supply, drug or equipment does not, in itself, make it medically necessary.

    Note: When a medical necessity determination is made utilizing the Aetna Clinical Policy Bulletins (CBPs), you may obtain a copy of Aetna's CPB through the following website:
    www.aetna.com/health-care-professionals/clinical-policy-bulletins/medical-clinical-policy-bulletins.html.

    Mental health/substance use disorder

    Conditions and diseases listed in the most recent edition of the International Classification of Diseases (ICD) as Mental, Behavioral, and Neurodevelopmental disorders.

    Observation care is a well-defined set of specific, clinically appropriate services, which include ongoing short term treatment, assessment, and reassessment, that are provided while a decision is being made regarding whether a patient will require further treatment as a hospital inpatient or whether the patient will be able to be discharged from the hospital. Observation services are commonly ordered for a patient who presents to the emergency room department and who then requires a significant period of treatment or monitoring in order to make a decision regarding their inpatient admission or discharge. Some hospitals will bill for observation room status (hourly) and hospital incidental services.

    If you are in the hospital for more than a few hours, always ask your physician or the hospital staff if your stay is consider inpatient or outpatient. Although you may stay overnight in a hospital room and receive meals and other hospital services, some hospital services-including “observation care”- are actually outpatient care. Since observation services are billed as outpatient care, outpatient facility benefit levels apply and your out-of-pocket expenses may be higher as a result.

    Any custom fitted external device used to support, align, prevent, or correct deformities, or to restore or improve function.

    Partial hospitalization

    Partial hospitalization programs must be licensed to provide mental health and/or substance use treatment. Services must be at least four hours per day and may include group, individual, and family therapy along with psychoeducational services and adjunctive medication management.

    Plan allowance

    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. We determine our allowance as follows:

    Network allowance: an amount that we negotiate with each provider or provider group who participates in our network. For these Network allowances, the Network provider has agreed to accept the negotiated reduction and you are not responsible for the discounted amount. In these instances, the benefit we pay plus any applicable deductible, copayment or coinsurance you are responsible for equals payment in full.

    If you receive a comprehensive preventive evaluation and management (E/M) service and a problem-oriented E/M service during the same office visit, the Plan’s allowance for the problem-oriented service will be 50% of the normal Plan allowance, unless the provider’s Network contract provides for a different amount.

    Non-Network allowance: the amount the Plan will consider for services provided by Non-Network providers. Non-Network allowances are determined as follows:

    If you receive a comprehensive preventive evaluation and management (E/M) service and a problem-oriented E/M service during the same office visit, the Plan’s allowance for the problem-oriented service will be 50% of the normal Plan allowance.

    Our Plan allowance is the lesser of: (1) the provider’s billed charge; or (2) the Plan’s Non-Network fee schedule amount. The Plan’s Non-Network fee schedule amount is equal to the 80th percentile amount for the charges listed in the Prevailing Healthcare Charges System, administered by Fair Health, Inc. The Non-Network fee schedule amounts vary by geographic area in which services are furnished. We base our coinsurance of this Non-Network fee schedule amount. This applies to all benefits in Section 5 of this brochure.

    For certain services, exceptions may exist to the use of the Non-Network fee schedule to determine the Plan’s allowance for Non-Network providers, including, but not limited to, the use of Medicare fee schedule amounts. For claims governed by OBRA ’90 and ’93, the Plan allowance will be based on Medicare allowable amounts as is required by law. For claims where the Plan is the secondary payer to Medicare (Medicare COB situations), the Plan allowance is the Medicare allowable charge.

    If you do not have adequate choice in selecting Network providers, please contact us prior to receiving services at 800-410-7778 for more information about Non-Network providers.

    For all dialysis services and all urine drug testing services, the Non-Network allowance is the maximum Medicare allowance for such services.

    Other Non-Network Participating Provider allowance:

    This Plan offers you access to certain other Non-Network healthcare providers that have agreed to discount their charges. Covered services at these participating providers are considered at the negotiated rate subject to applicable deductibles, copayments, and coinsurance. Since these other participating providers are not Network providers, Non-Network benefit levels will apply. Contact us at 800-410-7778 for more information about other Non-Network participating providers.

    For services received from other participating providers (see Other Participating Providers), the Plan’s allowance will be the amount the provider has negotiated and agreed to accept for the services and/or supplies. Benefits will be paid at Non-Network benefit levels, subject to the applicable deductibles, coinsurance and copayments.

    Network retail pharmacy allowance: the amount negotiated by the Plan’s pharmacy benefit manager with the pharmacy or pharmacy group at which the drug is purchased.

    Non-Network retail pharmacy allowance: the guaranteed discounted price for the drug negotiated by the Plan in its contract with its pharmacy benefit manager.

    Allowance for drugs provided by Network providers: the amount negotiated with each Network provider or provider group.

    Allowance for drugs provided by Non-Network providers:

    • 80% of the Average Wholesale Price (AWP) of the drug (or its equivalent if AWP data is no longer published)

    We apply Aetna claim editing criteria and/or the National Correct Coding Initiative (NCCI) edits published by the Centers for Medicare and Medicaid Services (CMS) in reviewing billed services and making Plan benefit payments for them.

    For more information, see Section 4, Differences between our allowance and the bill.

    You should also see Section 4, Important Notice About Surprise Billing – Know Your Rights for a description of your protections against surprise billing under the No Surprises Act.

    An artificial substitute for a missing body part such as an arm, eye, or leg. This appliance may be used for a functional or cosmetic reason, or both.

    A power-operated vehicle (chair or cart) with a base that may extend beyond the edge of the seat, a tiller-type control mechanism which is usually center mounted and an adjustable seat that may or may not swivel.

    Severe obesity

    A diagnosed condition in which the bodymass index is 40 or greater, or 35 or greater with co-morbidities such as diabetes, coronary artery disease, hypertension, hyperlipidemia, obstructive sleep apnea, pulmonary hypertension, weight-related degenerative joint disease, or lower extremity venous or lymphatic obstruction.

    A tooth that has sound root structure and an intact, complete layer of enamel or has been properly restored with a material or materials approved by the ADA and has healthy bone and periodontal tissue.

    Surprise bill

    An unexpected bill you receive for

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

    Urgent care center

    An ambulatory care center, outside of a hospital emergency department, that provides treatment for medical conditions that are not life-threatening, but need quick attention.

    Urgent care claims

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

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

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

    If you believe your claim qualifies as an urgent care claim, please contact our Customer Service department at 800-410-7778. You may also prove that your claim is an urgent care claim by providing evidence that a physician with knowledge of your medical condition has determined that your claim involves urgent care.

    Walk-in clinic

    A medical facility that accepts patients on a walk-in basis; no appointment is required. Provides non-emergency basic healthcare services on a walk-in basis. Examples include MinuteClinics® at CVS Pharmacy locations and Healthcare Clinics at Walgreens pharmacy locations. Urgent care centers are not considered walk-in clinics (See Urgent care center in this section.)

    You refers to the enrollee and each covered family member.

    (Page numbers solely appear in the printed brochure)

    • Accidental Injury
    • Acupuncture
    • Allergy
    • Alternative treatment
    • Ambulance
    • Anesthesia
    • Biofeedback
    • Biopsy
    • Blood and blood plasma
    • Cardiac rehabilitation
    • Care Management
    • Carryover
    • Casts/Casting
    • Catastrophic protection
    • Chemotherapy
    • Chiropractic
    • Cholesterol test
    • Claims
      • Disputed
      • Filing, Deadline
      • Filing, Medical
      • Filing, Overseas
      • Filing, Prescription
      • Post-service
      • Pre-service
      • Urgent care
      • Medicare
      • Education
      • Incentive program
      • Insulin
      • Supplies
      • Hospital, inpatient
      • Hospital, observation
      • Hospital, outpatient
      • Medicare Advantage
      • Medicare Part D
      • Original Medicare
      • Associate
      • Inpatient hospital
      • Professional services
      • Licensed Practical Nurse (LPN)
      • Registered Nurse (RN)
      • Covered medications
      • Formulary
      • Generic drug
      • Mail order
      • Network pharmacy
      • Non-network pharmacy
      • Non-preferred drug
      • Preferred drug
      • Specialty drug
      • Assistant surgeons
      • Bariatric
      • Co-surgeons
      • Cosmetic
      • Multiple
      • Oral
      • Reconstructive
      • Aetna Institutes of Excellence
      • Donor

      Do not rely on this chart alone. This is a summary. All benefits are subject to the definitions, limitations, and exclusions in this brochure. Before making a final decision, please read this FEHB brochure. You can obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at www.MHBP.com.

      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.

      Below, an asterisk (*) means the item is subject to the calendar year medical deductible of $350 per person (Network)/$600 per person (Non-Network). And, after we pay, you generally pay any difference between our allowance and the billed amount if you use a Non-Network physician or other healthcare professional.

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

      • Primary care provider: $20 copayment per office visit for adults; $10 copayment per office visit for dependent children through age 21;
      • Specialty provider: $30 copayment per visit
      • Diagnostic X-rays, laboratory services and other professional services: 10%* of the Plan’s allowance
      • Primary care provider and Specialty provider: 30%* of the Plan’s allowance and any difference between our allowance and the billed amount
      • Diagnostic X-rays, laboratory services and other professional services: 30%* of the Plan’s allowance and any difference between our allowance and the billed amount

      (Applies to printed brochure only)

      Services provided by a hospital: Inpatient

      Network: $200 copayment per admission and 10% of the Plan’s allowance for hospital ancillary services (No deductible)

      Non-Network: $500 copayment per admission; 30% of the Plan's allowance and any difference between our allowance and the billed amount (No deductible)

      (Applies to printed brochure only)

      Services provided by a hospital: Outpatient

      Network: 10%* of the Plan’s allowance

      Non-Network: 30%* of the Plan’s allowance and any difference between our allowance and the billed amount

      (Applies to printed brochure only)

      Emergency benefits: Accidental injury

      • Emergency room: $200 copayment per occurrence
      • Urgent care center: $50 copayment per occurrence
      • Emergency room: $200 copayment per occurrence and any difference between our allowance and the billed amount
      • Urgent care center: 30%* of the Plan’s allowance and any difference between our allowance and the billed amount

      (Applies to printed brochure only)

      Emergency benefits: Medical emergency

      • Emergency room: $200 copayment per occurrence*
      • Urgent care center: $50 copayment per occurrence*
      • Emergency room: $200 copayment* per occurrence and any difference between our allowance and the billed amount
      • Urgent care center: 30%* of the Plan’s allowance and any difference between our allowance and the billed amount

      (Applies to printed brochure only)

      Mental health and substance use disorder treatment

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

      (Applies to printed brochure only)

      Prescription drugs

      • Generic: $5 copayment per prescription
      • Preferred brand name: 30% of the Plan’s allowance and any difference between our allowance and the cost of a generic equivalent unless a brand exception is obtained, limited to $200 per prescription
      • Non-Preferred brand name: 50% of the Plan’s allowance and any difference between our allowance and the cost of a generic equivalent unless a brand exception is obtained, limited to $200 per prescription
      • Generic: $5 copayment per prescription and any difference between our allowance and the billed amount
      • Preferred brand name: 30% of the Plan’s allowance and any difference between our allowance and the cost of a generic equivalent unless a brand exception is obtained
      • Non-Preferred brand name: 50% of the Plan’s allowance and any difference between our allowance and the cost of a generic equivalent unless a brand exception is obtained

      Mail order drug program:

      • Generic: $10 copayment per prescription
      • Preferred brand name: $80 copayment per prescription and any difference between our allowance and the cost of a generic equivalent unless a brand exception in obtained.
      • Non-Preferred brand name: $120 copayment per prescription and any difference between our allowance and the cost of a generic equivalent unless a brand exception is obtained.
      • 15% of the Plan’s allowance for Generic/Preferred brand name, limited to $225 per prescription for a 30-day supply; 25% of the Plan's allowance for Non-Preferred brand name, limited to $275 per prescription for a 30-day supply
      • 15% of the Plan’s allowance for Generic/Preferred brand name, limited to $425 per prescription for a 90-day supply; 25% of the Plan's allowance for Non-Preferred brand name, limited to $500 per prescription for a 90-day supply

      (Applies to printed brochure only)

      Dental care

      Accidental injury; Oral surgery

      (Applies to printed brochure only)

      Special Features

      Care Management; Pain Management Program, Flexible Benefits Option; Compassionate Care program; Health Risk Assessment; Wellness Incentives; Lifestyle and Condition Coaching Program; Enhanced Maternity Program with family-building support powered by Maven; Personal Health Record; Discount Drug program; Round-the-clock Member Support

      (Applies to printed brochure only)

      Your catastrophic protection: out-of-pocket maximum

      Nothing after your covered medical and prescription drug expenses total:

      • $6,000/person ($12,000/family) per calendar year, for services, drugs and supplies from Network providers/facilities and pharmacies, combined
      • $9,000/person ($18,000/family) for services drugs and supplies from Non-Network providers/facilities and pharmacies, combined

      Some costs do not count toward this protection.

      (Applies to printed brochure only)

      Do not rely on this chart alone. This is a summary. All benefits are subject to the definitions, limitations, and exclusions in this brochure. Before making a final decision, please read this FEHB brochure. You can obtain a copy of our Summary of Benefits and Coverage as required by the Affordable Care Act at www.MHBP.com.

      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.

      Below, an asterisk (*) means the item is subject to the calendar year medical deductible of $600 per person (Network)/$900 per person (Non-Network). And, after we pay, you generally pay any difference between our allowance and the billed amount if you use a Non-Network physician or other healthcare professional.

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

      • Primary care provider: $30 copayment per office visit for adults; $10 copayment per office visit for dependent children through age 21
      • Specialty provider: $50 copayment* per office visit
      • Diagnostic X-rays, laboratory services and other professional services: 20%* of the Plan’s allowance
      • Primary care provider and Specialty provider: 40%* of the Plan’s allowance and any difference between our allowance and the billed amount
      • Diagnostic X-rays, laboratory services and other professional services: 40%* of the Plan’s allowance and any difference between our allowance and the billed amount

      (Applies to printed brochure only)

      Services provided by a hospital: Inpatient

      Network: 20%* of the Plan’s allowance

      Non-Network: 40%* of the Plan’s allowance and any difference between our allowance and the billed amount

      (Applies to printed brochure only)

      Services provided by a hospital: Outpatient

      Network: 20%* of the Plan’s allowance

      Non-Network: 40%* of the Plan’s allowance and any difference between our allowance and the billed amount

      (Applies to printed brochure only)

      Emergency benefits: Accidental injury/Medical emergency

      • Emergency room: 20%* of the Plan’s allowance
      • Urgent care center: 20% of the Plan’s allowance for an accidental injury; 20%* of the Plan's allowance for a medical emergency
      • Emergency room: 20%* of the Plan’s allowance and any difference between our allowance and the billed amount
      • Urgent care center: 40%* of the Plan’s allowance and any difference between our allowance and the billed amount

      (Applies to printed brochure only)

      Mental health and substance use disorder treatment

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

      (Applies to printed brochure only)

      Prescription drugs

      • Generic: $10 copayment per prescription
      • Preferred brand name: 45% of the Plan’s allowance and any difference between our allowance and the cost of a generic equivalent unless a brand exception is obtained; limited to $300 per prescription
      • Non-Preferred brand name: 75% of the Plan’s allowance, and any difference between our allowance and the cost of a generic equivalent unless a brand exception is obtained; limited to $500 per prescription

      Non-Network retail: All charges

      Mail order drug program:

      • Generic: $30 copayment per prescription
      • Preferred brand name: 45% of the Plan’s allowance and any difference between our allowance and the cost of a generic equivalent unless a brand exception is obtained; limited to $300 per prescription
      • Non-Preferred brand name: 75% of the Plan’s allowance, and any difference between our allowance and the cost of a generic equivalent unless a brand exception is obtained; limited to $700 per prescription
      • 50% of the Plan’s allowance for Generic/Preferred brand name, limited to $600 per prescription for a 30-day supply; 50% of the Plan's allowance for Non-Preferred brand name, limited to $700 per prescription for a 30-day supply
      • 50% of the Plan’s allowance for Generic/Preferred brand name, limited to $800 per prescription for a 90-day supply; 50% of the Plan's allowance for Non-Preferred brand name, limited to $850 per prescription for a 90-day supply

      (Applies to printed brochure only)

      Dental care

      Accidental injury; Oral surgery

      (Applies to printed brochure only)

      Special features

      Care Management; Pain Management Program, Flexible Benefits Option; Compassionate Care program; Health Risk Assessment; Wellness Incentives; Lifestyle and Condition Coaching Program; Enhanced Maternity Program with family-building support powered by Maven; Personal Health Record; Discount Drug program; Round-the-clock Member Support

      (Applies to printed brochure only)

      Your catastrophic protection: out-of-pocket maximum

      Nothing after your covered medical and prescription drug expenses total:

      • $6,600/person ($13,200/family) per calendar year, for services, drugs and supplies from Network providers/facilities and pharmacies
      • $10,000/person ($20,000/family) for services from Non-Network providers/facilities

      Some costs do not count towards this protection.

      (Applies to printed brochure only)

      To compare your FEHB health plan options please go to www.opm.gov/fehbcompare.

      To review premium rates for all FEHB health plan options, please go to www.opm.gov/FEHBpremiums or www.opm.gov/Tribalpremium.

      Premiums for Tribal employees are shown under the Monthly Premium Rate column. The amount shown under employee contribution is the maximum you will pay. Your Tribal employer may choose to contribute a higher portion of your premium. Please contact your Tribal Benefits Officer for exact rates.

      Nationwide
      Type of EnrollmentEnrollment CodePremium Rate
      BiWeekly
      Gov't Share
      Premium Rate
      BiWeekly
      Your Share
      Premium Rate
      Monthly
      Gov't Share
      Premium Rate
      Monthly
      Your Share
      Standard Option Self Only454$241.82$80.61$523.95$174.65
      Standard Option Self Plus One456$556.64$185.54$1,206.05$402.01
      Standard Option Self and Family455$561.98$187.33$1,217.63$405.88
      Nationwide
      Type of EnrollmentEnrollment CodePremium Rate
      BiWeekly
      Gov't Share
      Premium Rate
      BiWeekly
      Your Share
      Premium Rate
      Monthly
      Gov't Share
      Premium Rate
      Monthly
      Your Share
      Value Option Self Only414$174.62$58.20$378.33$126.11
      Value Option Self Plus One416$413.74$137.91$896.43$298.81
      Value Option Self and Family415$422.00$140.66$914.33$304.77
      Cover Page Mailhandler Medical Insurance Reviews (1)
Cover Page Mailhandler Medical Insurance Reviews (2024)
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