All Washington & Alaska Employees

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Welcome to PeaceHealth Employee Health Care Plans

Introduction

PeaceHealth is please to provide you with this comprehensive program of medical and prescription drug card coverage. Our goal is to help improve the health status of the communities in which we serve.

This booklet contains important information about the health plans PeaceHealth offers to its Corporate Center (Washington & Alaska Employees), Southeast Alaska Region, Lower Columbia Region and Whatcom Region employees. Healthcare Management Administrators, Inc. (HMA) serves as the Plan Supervisor for these Plans.

Please read this booklet carefully and particularly note the special requirements you must follow prior to having surgery or being admitted to a medical facility - this is explained in the "Prior Authorization" section.

If you have any questions regarding either your Plan's benefits or the procedures necessary to receive these benefits, please call HMA at 425/974-3886 (Seattle Metro Area) and toll free nationwide at 866/206-7786.

With this plan you are required to receive most covered services from a Preferred Provider.

About this handbook

This handbook is an explanation of your PeaceHealth Plan benefits.

It is important to carefully read this handbook. It will help you understand your benefits and responsibilities. If you don’t understand a term that is used, you may find it in the "Definitions" section.  If you need additional help understanding anything in this handbook, please call your Customer Service Team at HMA at 425/974-3886 (Seattle Metro Area) and toll free nationwide toll free at 866/206-7786.

This handbook is not complete without your Online Preferred Provider Directory for In-Network Plan members. Preferred Providers for the In-Network Plan are listed online at www.regence.com. Providers must participate in the Regence Washington and Oregon PPO panel to be considered a Preferred Provider. You will need this directory to be able to access covered services. We also have a list of Preferred Providers in a paper directory. To obtain a paper directory, call your Customer Service Team or check with your employer’s human resource department.

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Benefit Summary

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Mental Health & chemical Dependency

All mental health and chemical dependency treatment, inpatient and outpatient, must be pre-authorized. Failure to pre-authorize may result in the denial of your claim.

For employees working in Southeast Alaska Region, Corporate Office or Lower Columbia Region, contact Mental Health Match at 1-800-457-3798 for pre-authorization.

For employees working in the Whatcom Region, contact Health Promotion Network at 1-800-244-6142 or 360/715-6575 for pre-authorization.

	Mental Health		Chemical Dependency Combined Inpatient and Outpatient limited to $10,000 every two calendar years
	You Pay	Limits	You Pay
Inpatient	20%	30 days every 24 months	20%
Outpatient**	20%	20 visits per calendar year	20%

**Does not apply to the out-of-pocket maximum.

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Prescription Drugs

Retail and Mail Order Prescription Co-pays
	Retail (30 day supply)	Mail Order (90 day supply)
Generic	$7 copay	$14 copay
Formulary Drugs	$12 copay	$24 copay
Non-Formulary Drugs	50% coinsurance	50% coinsurance
Combined retail and mail order $1,000 out-of-pocket maximum. $18 minimum for non-formulary drugs.

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Customer Service

We want you to understand how to use your PeaceHealth Plan benefits. We also want you to be satisfied with your health plan. We are here to help and are always glad to answer any questions you have about using your health plan.

How to contact your Customer Service Team

Your HMA Customer Service Team will handle all your needs including claims, enrollment and customer service issues. Here’s all you need to do to get in touch with your Customer Service Team:

Have your HMA member identification card ready when you call. Your card lists your member number.

• If you live in:

  • The Seattle Metro Area: Call 425/974-3886.

  • All other areas: Call 1-866-206-7786.

Your HMA Customer Service Team is available from 8:00 a.m. to 5:00 p.m., Monday through Friday.

For your information

Your Customer Service Team is available to help you understand your benefits and resolve any problems. Your team will handle:

• Specific benefit or claim questions.

• Questions or concerns about adding or dropping a dependent.

• Enrollment issues.

• Questions or concerns about your health care or service.

When contacting the HMA Customer Service Department, answers for benefits and eligibility will be provided to any participant and to providers of service. The benefits quoted by HMA are not a guarantee of claim payment. Claim payment will be dependent upon eligibility at the time of service and all terms and conditions of the Plan. This disclaimer will be provided to the caller when benefits are quoted over the telephone.

For a written pre-estimate of benefits, a provider of service must submit to the Plan Supervisor his or her proposed course of treatment, including diagnosis, procedure codes, place of service and proposed cost of treatment. In some cases, medical records or additional information may be necessary to complete the pre-estimate.

When the Medical Review Coordinator at HMA pre-authorizes any confinement, procedure, service or supply, it is only for the purpose of reviewing whether the service is determined to be medically necessary for the care of the treatment or illness. Pre-authorization does not guarantee payment of benefits. All charges submitted for payment are subject to all other terms and conditions of the Plan, regardless of authorization by the Medical Review Coordinator whether by telephone or in writing.

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General Information

Prior authorization

Prior authorization is required for the following services:

• All inpatient admissions, including admission to a hospital, skilled nursing facility or a rehabilitation facility and maternity delivery. For emergency hospitalizations, you, or a relative, need to notify the Plan within 48 hours, or as soon as reasonably possible.

• All outpatient surgical procedures.

• All non-emergency mental health and chemical dependency services must be prior authorized by:

  • Mental Health Match at 1-800-457-3798
    (Corporate Office, Southeast Alaska Region, Lower Columbia Region and Corporate employees located in Southeast Alaska and Lower Columbia Region).

  • Health Promotion Network at 1-800-244-6142 or 360/715-6575 (for Whatcom Region employees, Corporate employees located in the Whatcom region).

• All human organ/tissue transplant related services.

• All hospice services.

• Medical supplies, durable medical equipment, appliances and prosthetic devices in excess of $500.

• Temporomandibular joint syndrome (TMJ) services (surgical procedures only).

• All outpatient hospitalization and anesthesia for covered dental services.

Failure to call for pre-authorization five days prior to an outpatient surgery or an admission into a medical facility or, in the case of an emergency admission, failure to obtain authorization either within 48 hours after the emergency admission or on the next business day, if later, will result in the denial of your claim. These penalty amounts do not apply to your out-of-pocket maximums or deductibles.

Getting services prior authorized

For all services (except non-emergency mental health and chemical dependency services), call HMA’s Medical Review Department at 866/206-7786 to obtain prior authorization.

When you call to request prior authorization, please be prepared to give the following information:

• Member’s name.

• Member’s health plan identification number and group number (these numbers are listed on your PeaceHealth Plan member identification card).

• Member’s date of birth.

• Medical Facility name and address.

• Scheduled date of admission, or date services are to begin.

• Treatment or procedure to be performed.

The Medical Review Coordinator will send written confirmation of the approved admission to the patient once authorized.

Pre-authorization does not guarantee payment of benefits.

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Member identification card

Each member of the PeaceHealth Plan receives a member identification card. You must have this card to identify you as a Plan member. Your member identification card lists your member number, your health plan and important phone numbers.

When scheduling an appointment or receiving Plan services, identify yourself as a PeaceHealth Plan member, present your member identification card and pay your copayment or coinsurance.

Please keep your health plan member card with you and use it when you:

• Have appointments with your personal physician/provider or other Preferred Provider. If you are an enrolled Out-of-Area Dependent, please present your card to any non-Preferred Providers you are seeing.

• Call for mental health/chemical dependency customer service.

• Call or write your HMA Customer Service Team.

• Receive urgent or emergency health care.

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Using Your Plan's In-Network Benefits

Introduction

This section summarizes basic information you need to know to take advantage of the benefits offered by your PeaceHealth health plans.

Preferred Providers

PeaceHealth has contracted for arrangements with certain physicians/providers. These providers are called "Preferred Providers." The agreements with these providers enable you to receive quality health care for a reasonable cost. For in-network benefits to be covered, you must receive health care services from Preferred Providers. Your Preferred Provider will work with the Plan and HMA to arrange for any Plan prior authorization requirements that may be required for certain covered services.

In-Network Plan members designated as Out-of-Area Dependents have a special Out-of-Area benefit allowing them to use non-Preferred Providers. For further information, see "Enrolled Out-of-Area Dependent Benefits," section.

To encourage optimum health, we promote wellness and preventive care. We also believe wellness and overall health is enhanced by working closely with one physician or provider – your personal physician/provider. He or she can provide most of your care and can track all of your medical care to avoid unneeded or conflicting treatment. To encourage this relationship, your out-of-pocket costs for office visits with a preferred personal physician/provider are generally lower. You can, however, see any Preferred Provider you want for covered medical services. When you do this, your out-of-pocket costs will generally be higher. The choice is up to you.

If you are unsure about a provider’s, hospital’s or other facility’s participation in PeaceHealth Plan visit the Online Regence Preferred Provider Directory at www.regence.com before you make an appointment. You also can call your HMA Customer Service Team to get information about a provider’s participation with PeaceHealth Plan.

We encourage our members to use the Online Preferred Provider Directory for Preferred Provider and hospital information. The online directory is updated on a frequent basis and includes additional information on each provider.

Personal physicians/providers

We recommend that upon enrolling in the Plan you and each of your family members choose a preferred personal physician/provider from the Regence Preferred Provider Directory as soon as possible. If you live in the Seattle Metro area, you can call HMA at 425/974-3886 or 866/206-7786 for help in choosing a physician or provider.

In most cases, personal physicians/providers specialize in one or more of the following areas of medicine: family practice, internal medicine, pediatrics, general practice or nurse practitioner practice. In some instances, physicians or providers who specialize in obstetrics/gynecology also may be personal physicians/providers. Your personal physician/provider can provide most of your care and, when necessary, coordinate care with other providers in a convenient and cost-effective manner. Personal physicians/providers provide preventive care and health screening, medical management of many chronic conditions, allergy shots, treatment of some breaks and sprains, and care for many major illnesses and nearly all minor illnesses and conditions. Many personal physicians/providers offer maternity care and minor outpatient surgery as well.

Established patients with personal physicians/providers

If you and your family already see a pediatrician, family practitioner and/or internist regularly, check the preferred provider directory to see if your provider is a preferred physician/provider for the PeaceHealth Plans.

Selecting a new personal physician/provider

If you don’t have a regular personal physician/provider or your provider is not a preferred provider, we recommend you choose one from the Regence Preferred Provider Directory for each covered member of your family. Call the provider’s office to make sure he or she is accepting new patients.

Soon after you select your personal physician/provider, it is a good idea to have your previous physician or provider transfer your medical records to your new personal physician/provider. On your first visit make a list of questions or information you would like to discuss with your new personal physician/provider, including the following:

• What are the office hours?

• How can I get medical advice after hours?

• What do I do in an emergency?

• Let your personal physician/provider know if you are under a specialist’s care.

• Inform your personal physician/provider of any ongoing prescription medications you are currently taking.

Some women’s health care providers may be approved to serve as personal physicians/providers. These women’s health care providers include physicians specializing in obstetrics or gynecology, nurse practitioners, certified nurse midwives, or physician’s assistants specializing in women’s health care.

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Changing your personal physician/provider

You are encouraged to establish an ongoing relationship with your personal physician/provider. We understand, however, how important it is for you and your family to feel confident in your choice of providers. If you decide to change your personal physician/provider or your personal physician/provider is no longer preferred with the Plan, simply choose a new one from the Preferred Provider Directory and begin seeing him or her the next time you need medical care. Please remember to have your medical records transferred to your new personal physician/provider.

Personal physician/provider office visits

We recommend you see your personal physician/provider for all routine care and call your personal physician/provider first for urgent or specialty care. If you need medical care when your personal physician/provider is not available, the personal physician/provider on call may treat you and/or recommend that you see another Preferred Provider who specializes in treatment for your condition.

.Whenever you visit your personal physician’s/provider’s office:

• Bring your HMA member identification card with you.

• Make your copayment before you leave your personal physician’s/provider’s office.

Office visits to other Preferred Providers (specialists)

When your personal physician/provider decides you need diagnostic tests or other specialist services, he or she will discuss it with you. Your personal physician/provider may recommend you see a preferred specialist for your condition.

You also may decide to see a preferred specialist without consulting your personal physician/provider. Check our Online Regence Preferred Provider Directory at www.regence.com to make sure the provider you choose is a Preferred Provider with the Plan. You also can contact your HMA Customer Service Team to verify whether or not a provider is preferred with the Plan.

If you decide to see a preferred specialist on your own, we recommend you let your personal physician/provider know about your decision. Your personal physician/provider will then be able to coordinate your care and share important medical information with your specialist. In addition, we recommend you let your specialist know the name and contact information of your personal physician/provider.

Whenever you visit a preferred specialist:

• Bring your HMA member identification card with you.

• Since in most cases your out-of-pocket costs will be a percent of billed services, you will most likely not be able to pay for what you owe at the time of your visit. Your provider’s office will send you a bill for what you owe later. Some providers, however, may ask you to pay for an estimate of what you may owe at the time you receive services and bill or credit you for the balance later.

Claims payment

All preferred physicians, providers and hospitals submit claims directly to the address listed on your HMA medical identification card. If you receive services from a preferred personal physician/provider and have already paid all of your out-of-pocket costs to that provider, he or she may send you an informational statement after billing HMA. If you receive services from other preferred providers, you most likely will receive a bill from your provider’s office for the percentage of coinsurance that you owe unless you paid this when you were in the provider’s office. Pay your provider’s office the amount you owe. Do not pay this amount to HMA.

Explanation of Benefits (EOB). You will receive an EOB after your claim has been processed. An EOB is not a bill. An EOB explains how your claim was processed, and will assist you in paying the appropriate member responsibility to your provider. Copayment or coinsurance amounts, services or amounts not covered and general information about our processing of your claim are explained on an EOB.

If you see a non-Preferred Provider for a covered service, please send an itemized statement directly to:

HEALTHCARE MANAGEMENT ADMINISTRATORS, INC.

PO Box 85008

Bellevue, WA 98015

All claims for reimbursement must be submitted within one year of the date incurred or they will be denied.

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Annual Out-of-Pocket Maximums

In-Network annual out-of-pocket maximums

Your In-Network Plan has both a per person and per family annual (calendar year) out-of-pocket maximum. These amounts are listed on your In-Network Plan Summary of Benefits. Your maximums are the total amount you or your covered dependents will pay out-of-pocket in any calendar year for covered services. The family maximum combines out-of-pocket costs made by all family members. Once you or your family have paid the maximum amounts listed on your Summary of Benefits, you will have no additional out-of-pocket costs for covered services for the remainder of the calendar year.

Out-of-pocket costs that do not apply to maximums

For all plans, the following out-of-pocket costs do not apply toward your annual out-of-pocket maximum:

• Services not covered under the Plan.

• Services in excess of any maximum benefit limit.

• Fees in excess of the usual, customary and reasonable (UCR) charges.

• Durable medical equipment and medical supplies and devices.

• Services relating to the diagnosis of infertility.

• Any penalties you must pay if you do not follow the Plan’s prior authorization requirements.

• Payments you make toward meeting any applicable calendar year deductibles.

• Services related to outpatient mental health treatment.

• Services related to smoking cessation treatment.

• Copayments or coinsurance for any supplemental benefits your plan may have such as alternative care or chiropractic care.

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Enrolled Out-of-Area Dependent Benefits

Introduction

Dependents who live outside the Regence Preferred Provider service area (including dependents who are away at school) are eligible to become Out-of-Area Dependent members. See the "Definitions," section for the Plan’s definition of "dependent" and "Out-of-Area dependent."

This section discusses how enrolled Out-of-Area Dependents can obtain covered services through the Plan’s Out-of-Area benefit.

Enrollment

Out of Area Dependents - To apply for Out-of-Area Dependent benefits, complete an Out-of-Area Dependent Enrollment form, available from your Human Resources Department. If you do not complete an Out-of-Area Dependent Enrollment form, your Out-of-Area Dependent will not be covered for Out-of-Area Dependent benefits.

Coverage

When you enroll for Out-of-Area coverage, we will send you an Out-of-Area Summary of Benefits. As stated on your Summary of Benefits, a member with Out-of-Area benefits may see any provider, in or out of the service area. The Plan will pay up to 80 percent of covered charges, with no deductible for eligible benefit services. The Plan’s payment is based on usual, customary and reasonable charges (UCR). Charges which exceed UCR are the member’s responsibility and are not applied to the member’s annual $1000 out-of-pocket maximum. For a more thorough explanation on UCR charges, see the "How the Plan Pays for Non-Preferred Provider Covered Services (UCR)," section.

Additional Information:

• See "Approved Non-Preferred Provider Categories," for information regarding Plan-approved non-Preferred Providers.

• See "Submitting Claims for Non-Preferred Providers," for information on payment of non-Preferred Provider claims.

• See the Out-of-Area Summary of Benefits for specific coverage information.

Prior authorization

Prior authorization is required for certain covered services enrolled Out-of-Area members receive. For a list of these services and how to obtain prior authorization, see the "Prior Authorization," section.

Change of status

Enrolled Out-of-Area Dependents
These members may change to the subscriber’s In-Area plan benefits when they return to our service area. If they do so, they will receive In-Area benefits. They also must follow Plan procedures for the In-Area plan.

Members who change their status must wait at least 30 days before switching again. For example, if your dependent child returned to our service area for summer vacation, you would need to contact your Human Resources Department to change the child back to In-Area coverage. Then, to be eligible for Out-of-Area coverage again, your child would need to have been covered under the In-Area benefit plan for at least 30 days.

If your dependent comes home for a short visit that is less than 30 days (for example, during Christmas vacation), coverage will remain at the 80 percent Out-of-Area benefit level. Please call your Human Resources Department if you have any questions on a change of status for dependents.

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Non-Preferred Providers

Introduction

This section summarizes basic information for In-Network Plan members using the out-of-network benefit on obtaining covered services from non-Preferred Providers. (Generally, except for emergency or urgent situations outside the Plan’s service area, In-Area In-Network Plan members cannot obtain covered services from non-Preferred Providers unless they are enrolled Out-of-Area Dependents.)

Prior authorization

Prior authorization is required for inpatient admissions and outpatient surgeries received the services from a non-Preferred Provider. Please see the "Prior Authorization" section (under General Information) for specific information on requirements and penalties.

Approved non-Preferred Provider categories

When you use non-Preferred Providers, the Plan provides benefits for covered medically necessary care only when it is received from providers or facilities in approved categories, and when the provider is practicing within the scope of his or her license.

The Plan has approved and may provide reimbursement for non-preferred qualified practitioners and facilities. Qualified practitioners are defined as a physician, women’s health care provider, nurse practitioner, clinical social worker, physician assistant, psychologist, dentist, or other practitioner who is professionally licensed by the appropriate state agency to diagnose or treat a bodily injury or illness and who provides services covered by the Plan within the scope of that license. A qualified facility is defined as a facility, institution or clinic duly licensed by the appropriate state agency, which is primarily established and operating within the lawful scope of its license.

Important Note: While the Plan will provide reimbursement for covered services received by any of the Plan approved providers listed above, for benefits to be paid you must receive medically necessary covered services as listed in this handbook. All treatment, supplies, and medications excluded by the Plan are not covered no matter what type of approved category of provider you see.

How the Plan pays for non-Preferred Provider covered services (UCR)

The Plan’s payment to non-Preferred Providers is based on usual, customary and reasonable charges (UCR). Charges which exceed UCR are the member’s responsibility and are not applied to the out-of-pocket maximum.

Example on how UCR charges and your coinsurance for non-Preferred Providers is calculated.

UCR calculations are complicated and vary by type of service and where the service is received. There is no precise method for determining the UCR amount until after the provider bills HMA for the services you receive.

Submitting claims for non-Preferred Providers

Many health care providers will submit the bill for you. Please be sure to show your member identification card to your provider. If your provider does not bill directly, request an itemized bill suitable for insurance purposes. Send this information with your member identification number on it to:

HEALTHCARE MANAGEMENT ADMINISTRATORS, INC.

PO Box 85008

Bellevue, WA 98015

To ensure timely processing of claims, you are encouraged to submit a claim for treatment within 60 days of the date of services. The Plan will not pay claims received more than 12 months after the date of service.

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Emergency and Urgent Care

Definition of an emergency or urgent care situation

A medical emergency is a sudden unexpected illness or injury that you believe would place your life in danger or cause serious damage to your health if you do not seek immediate medical treatment. Medical emergencies include, but are not limited to:

• Heart Attack

• Acute abdominal pain

• Stroke

• Severe chest pain

• Poisoning

• Serious burn

• Loss of consciousness

• Bleeding that does not stop

• Medically necessary detoxification

The definition of an "Emergency medical condition" is a medical condition that manifests itself by symptoms of sufficient severity that a prudent lay person, possessing an average knowledge of health and medicine, would reasonably expect that failure to receive immediate medical attention would place the health of a person (or a fetus in the case of a pregnant woman) in serious jeopardy.

"Emergency Services" are those health care items and services furnished in an emergency department. Services include all ancillary services routinely available to an emergency department to the extent they are required for the stabilization of the patient.

"Emergency Medical Screening Exams" include medical history, examination, ancillary tests and medical determinations required to ascertain the nature and extent of an emergency medical condition.

Your health plan benefits cover emergency services in the emergency room of any hospital in or outside the Plan service area. Emergency room services are covered when your medical condition meets the guidelines for emergency care as stated above. Coverage includes services to stabilize an emergency medical condition and emergency medical screening exams.

What to do if you have an emergency

If you or a family member believe that immediate assistance is needed for an emergency medical condition, call 9-1-1 or go to the nearest emergency room. Tell the emergency personnel the name of your personal physician/provider and show them your HMA member identification card.

If you’re not sure it’s an emergency

Call your personal physician/provider any time, any day of the week. Your personal physician/provider, or the personal physician/provider on call, will tell you what to do and where to go for the most appropriate care. You also may call HMA at 866/206-7786, if you’re not sure whether to call your personal physician/provider or go to the emergency room. If you believe that taking time to call your personal physician/provider or HMA would threaten your life or cause serious damage to your health, call 9-1-1 or go to the nearest emergency room.

Emergency care in the service area and outside the service area

If you are in the Plan’s service area and need emergency services, try to go to the nearest preferred hospital. If additional travel time to a preferred hospital would endanger your life, or if you are more than 30 miles away from a preferred hospital, go directly to the nearest hospital.

If you are outside the Plan’s service area and need emergency services, go to the nearest hospital.

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Emergency room copayment

You are responsible for your plan’s copayment/coinsurance whenever you receive services in an emergency room, unless you are admitted to a hospital within 24 hours. Please be prepared to pay your copayment/coinsurance at the time you receive care. You are responsible for your plan’s copayment/ coinsurance for each hospital emergency room visit. Please refer to your Summary of Benefits for your copayment/coinsurance amounts and any applicable deductibles.

Services not covered

The Plan does not pay for emergency room treatment for medical conditions that are not medical emergencies. Do not go to the emergency room for care that should take place in your provider’s office. Routine care for sore throats, common colds, follow-up care, and prescription drug requests are not considered to be emergencies.

Eye emergencies

If you have an emergency medical condition involving injury or illness to your eye(s), you may receive services directly from an optometrist or ophthalmologist or a hospital emergency room.

Psychiatric emergency

Emergency services are provided for psychiatric, mental health and chemical dependency conditions that in the reasonable judgment of a prudent layperson would place your life in danger or cause serious damage to your health if immediate care is not received. If you have a psychiatric emergency or crisis and receive emergency treatment at a specialized mental health facility that handles emergency care, the emergency room copayment/coinsurance will apply.

What to do if you are admitted to a non-preferred hospital

If you are admitted to a non-preferred hospital, you, or a relative, should call HMA within 48 hours or as soon as reasonably possible. All approved services will be covered at usual, customary and reasonable (UCR) charges. You will be responsible for any copayments and all amounts above the UCR charges.

You will need to submit a claim for a non-preferred hospital service if the provider does not submit it for you. For information on how to submit a claim, see "Additional Information," on the next page.

Urgent/immediate and after-hours care

Urgent care is treatment you need right away for an illness or injury that is not life threatening. This includes, but is not limited to, minor sprains, minor cuts and burns, and ear, nose, and throat infections. Routine care that can be delayed until you can be seen by a physician or provider in his or her office is not urgent care.

Whenever you need urgent care, call your personal physician/provider first. You also may call HMA at 866/206-7786, if you’re not sure whether to call your personal physician/provider or go to the urgent care center. Your personal physician/provider or personal physician/provider on call is always available, day or night. He or she may either suggest that you come to the office, or go to an emergency room or urgent care facility. If you can be treated in your provider’s office or preferred urgent care facility, your copayment/coinsurance usually will be lower. You are responsible for your plan’s copayment/coinsurance whenever you receive services in an urgent care clinic, unless you are admitted to a hospital within 24 hours. Please be prepared to pay the copayment/coinsurance at the time you receive care.

If you are admitted to a non-preferred hospital, you, or a relative, should call the Plan within 48 hours or as soon as reasonably possible.

The Plan pays for urgent care wherever you are. If you are injured or seriously ill while you are away from the Plan service area, go to any provider or urgent care facility.

The Plan does not cover non-urgent care such as check-ups or follow-up care while you are outside the Plan service area.

For urgent care services inside the Plan’s service area, please try to go to a preferred urgent care facility.

Additional Information

If you receive services from an urgent care facility or emergency room from a non-preferred facility outside or inside the Plan’s service area, you must submit a claim if the facility or provider does not submit it for you. Submit claims to:

HEALTHCARE MANAGEMENT ADMINISTRATORS, INC.

PO Box 85008

Bellevue, WA 98015

We request that you submit your claim within 60 days of receiving the service. To be paid, claims must be submitted within 12-months of receiving the service.

Please call HMA at 866/206-7786 if you have questions about this benefit or if you would like additional information.

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Benefits

Introduction

This section lists your covered benefits in the same order that they appear on your Summary of Benefits. Please refer to your Summary of Benefits for your member copayments coinsurance as well as other details of your specific coverage. If the Plan is required by law to modify your benefits, you will be notified in writing prior to any changes.

Except as otherwise stated in the "Using Your Plan's In-Network Benefits," section, you must use preferred providers to receive benefits for the covered services listed in this section.

Eligible Expenses

When medically necessary for the diagnosis or treatment of an illness or an accident, the following services are eligible expenses for participants covered under this Plan. Eligible expenses are payable as shown in the Schedule of Benefits and are limited by certain provisions listed in the General Exclusions. Major Medical expenses are subject to all Plan conditions, exclusions and limitations.

Preventive Health Services

This benefit covers routine physician services and related diagnostic tests that are regularly performed without the presence of symptoms. Your provider will determine which tests are necessary for your physical exam according to your medical history and your current health status. More frequent exams will be covered if your provider determines that they are necessary. Services are payable as shown in the Schedule of Benefits. Routine exams and tests are covered according to the following schedule:

Recommended guidelines:

• Well baby care, up to eight provider office visits during a child’s first 24 months.

• For children age 2-6, one exam per year.

• For children age 7-18, one exam every 24 months.

• For adults age 19-29, one exam every 60 months.

• For adults age 30-39, one exam every 36 months.

• For adults age 40-49, one exam every 24 months.

• For adults age 50 and above, one exam every year.

If, at the time of your routine physical examination or well child care, you need paperwork completed for a third party such as school, camp, team sports, etc., your provider may charge you a fee to complete the paperwork. The Plan will not cover this additional fee.

Immunizations/vaccinations

Routine immunizations/vaccinations (shots) are covered. Coverage forimmunizations is provided when ordered or arranged by your provider and received in the provider’s office. Visits to your provider’s office for immunizations are subject to a copayment or member coinsurance. Immunizations required for travel, employment, insurance, licensing purposes or solely for the purpose of preferred in camps, sports activities, recreation programs, or college entrance are not covered.

Children’s vision and hearing screenings

Annual vision and hearing screenings by a provider are covered for children through age 17. If a vision or hearing problem is discovered, the Plan will pay for one visit per calendar year to an eye or hearing specialist to determine the need for vision or hearing correction.

Covered services do NOT include:

• Services for laser surgery, radial keratotomy and any other surgery to correct myopia, hyperopia or stigmatic error; vision therapy, or orthoptic treatment (eye exercises).

• Services for routine eye and vision care, refractive disorders, eyeglass frames and lenses, and contact lenses.

• Hearing aids, including all services related to the examination and fitting of the hearing aids.

Members diagnosed with diabetes

Members diagnosed with either insulin dependent or non–insulin dependent diabetes mellitus, have the following preventive health care benefits:

• Diabetes Education

• Dietary Counseling is covered up to two visits per calendar year

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Women’s Health Care Services

Annual gynecological exams

Benefits for annual gynecological examinations include breast, pelvic and Pap examinations once every 12 months, or more frequently if your provider determines that they are necessary.

Female members may receive preventive women’s care exams from their personal physician/provider or from any other qualified provider who specializes in women’s health care. Women’s health care providers include physicians specializing in obstetrics or gynecology, nurse practitioners, certified nurse midwives, or physician assistants specializing in women’s health care.

Benefits also include follow-up exams for any medical conditions discovered during an annual gynecological exam that require additional treatment Your follow-up visit copayment/coinsurance may differ from your annual gynecological exam copayment/coinsurance. See your plan’s Summary of Benefits for details on your copayment/coinsurance information.

Mammograms

Mammograms are provided for women at the recommendation of your personal physician/provider or women’s health care provider.

Other Services

Counseling, exams and some services for voluntary family planning are covered. Contact HMA or your Human Resources department for detailed information.

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Physician/Provider Services

If you receive office visit services from a preferred personal physician/provider, you may be responsible for charges for services and supplies received from your personal physician/provider in addition to your member copayment. For example – You see your personal physician/provider for an office surgery. You would pay your office visit copayment and also may need to pay additional coinsurance for the office surgery and any medical supplies used for your surgery. See your plan’s Summary of Benefits for details.

Office visits & office surgery

For covered services, the Plan pays the balance in full after you pay your member copayment/coinsurance. Your Summary of Benefits lists your copayment/coinsurance information for various types of office visits.

If you are unable to keep a scheduled office appointment with your provider, please try to notify that office in advance. The Plan does not cover charges for missed appointments.

Inpatient hospital visits

Provider visits in the hospital for approved hospitalization, including skilled nursing facilities, are covered.

Surgery and anesthesia

The Plan will cover provider charges for medically necessary surgery. This may include the fees of a surgeon, an assistant surgeon(s) and an anesthesiologist or registered nurse anesthetist. If two or more surgical procedures are performed through the same incision during an operation, full benefits are only provided for the primary procedure and one half for the lesser procedure. You are responsible for making sure the services are prior authorized by the Plan.

Assistant surgeon fees are limited to 20% of the primary surgeon’s fees.

Some surgical procedures are covered by the Plan only when performed on an outpatient basis. Your provider and/or the Plan will tell you in advance if your procedure is an outpatient surgery.

Allergy shots or injections

Allergy testing, shots or injections are covered. Your member coinsurance for allergy shots is listed on your Summary of Benefits.

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Hospital Services

Hospital services are covered, as stated on your Summary of Benefits. The Plan may require that you obtain a second opinion for some elective procedures. If you do not obtain a second opinion when requested, the Plan will not prior authorize the services and you will be responsible for paying for all of the services you receive.

Covered services do NOT include care received that consists primarily of:

• Room and board and supervisory or custodial services.

• Personal hygiene and other forms of self-care.

• Non-skilled care for senile deterioration, mental deficiency or mental retardation.

In all cases the following are specifically excluded from the hospital and skilled nursing facility benefit:

• Private duty nursing or a private room unless prescribed as medically necessary.

• Take-home medications, supplies and equipment.

• Personal items such as telephone, radio, television and guest meals.

Inpatient acute care

When an inpatient admission or surgery is recommended, the patient, the physician or a family member must call the HMA Medical Review Coordinator at least five days prior to the admission or surgery to obtain authorization. Please see the "Prior Authorization" section (under General Information) for specific information on requirements and penalties.

Only medically necessary hospital services are covered. Covered inpatient services received in a hospital are:

• Acute (inpatient) care, when medically necessary.

• A semi-private room (unless a private room is medically necessary).

• Coronary care and intensive care, when necessary.

• Isolation care, when necessary.

• Hospital services and supplies necessary for treatment and furnished by the hospital, such as operating and recovery rooms, anesthesia, dressings, medications, oxygen, x-ray, and laboratory services during the period of inpatient hospitalization. (Personal items such as guest meals, slippers, etc., are not covered.)

The Plan employs professional clinical staff who may review services you receive in the hospital. They may review your care to determine medical necessity, to make sure that you had quality care and to ensure that you will have proper follow-up care.

Your provider will determine your medically appropriate length of stay. If you choose to stay in the hospital longer than your physician advises, you will be responsible for the cost of additional days in the hospital.

Inpatient rehabilitative care

Inpatient rehabilitative care is covered. This applies when you need a full rehabilitation team approach and the services can be provided to you only as an inpatient. These services must be part of your provider’s treatment program to improve lost function after an illness or an injury. If you are hospitalized when rehabilitative services begin, rehabilitative benefits will begin on the day treatment becomes primarily rehabilitative. Inpatient rehabilitative care is limited to 30 days per calendar year as stated on your Summary of Benefits.

Skilled nursing facility

Skilled nursing facility services are covered when 24-hour skilled or subacute care is required and cannot adequately be provided through a home health program. Only medically necessary services are covered. The Plan may determine that your care needs are better served by transferring you from the hospital to a skilled nursing facility and reserves the right to make such a transfer. Services must be prescribed by your provider and prior authorized by the Plan. The Plan will cover up to 60 days of medically necessary care per calendar year as stated on your Summary of Benefits.

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Maternity Services

Selecting a physician or provider

The Plan covers comprehensive maternity care. Women may go to their personal physician/provider or a women’s health care provider of their choice for obstetric care once pregnancy has been diagnosed. Women’s health care providers include physicians specializing in obstetrics, some personal physicians/ providers (if they provide obstetric services), nurse practitioners, certified nurse midwives or physician assistants specializing in women’s health care.

Covered services

• Normal delivery.

• Cesarean delivery.

• Prenatal care by your physician, provider or certified nurse midwife.

• Birth at an approved facility.

• Postnatal care, including complications of pregnancy and birth.

• Newborn nursery care.

• Emergency treatment for complications of pregnancy and unexpected pre-term birth outside the service area.

The following services are NOT covered:

• Home births and services of a lay midwife.

• Maternity services provided for an unexpected premature delivery outside of the service area are covered as emergency services, as stated above. However, after the 36th week of pregnancy, delivery is not considered to be unexpected. Covered services for deliveries outside the service area are NOT covered as an emergency service unless the Plan determines that you were outside the service area because of circumstances beyond your control. (Does not apply to enrolled Out-of-Area Dependents.)

Length of hospital stay

You will not be discharged from the hospital sooner than 48 hours after a vaginal delivery or 96 hours after a caesarean delivery, unless you choose to be. You and your physician/provider will determine the length of your hospital stay and follow-up care based on accepted medical practice.

Newborn coverage

Select a family practitioner or pediatrician (personal physician/provider) for your baby. As soon as possible after delivery, add your newborn to your Plan coverage by contacting your employer and/or your Customer Service Team. Your baby is covered by PeaceHealth Plan for only 31 days after birth unless we receive a completed enrollment form from you or your employer within 60 days. See the "Newly-acquired dependents," section, for additional information.

Infertility services

Services for the treatment of infertility are covered the same as relevant services as listed on your Summary of Benefits. You must see a Preferred Provider for services to be covered. (Enrolled Out-of-Area Dependents may use a non-Preferred Provider for these services.)

Covered services are limited to: Diagnostic testing and associated office visits to determine the cause of infertility. This includes the physical examination, related laboratory testing, instruction, and medical/surgical procedures when performed for the sole purpose of diagnosing an infertile state. Diagnostic services for infertility include, but are not limited to hysterosalpingogram, laparoscopy and pelvic ultrasound.

All other infertility services are not covered. These include, but are not limited to:

• In-vitro fertilization;

• In-vivo fertilization

• Gamete inter-fallopian transfer (GIFT);

• Reversal of sterilization (tubal ligation or vasectomy); and

• Any method of artificial insemination, including any and all supplies, services, drugs, and treatments leading up to the procedure of artificial insemination, and until impregnation is confirmed.

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Medical and Diabetes Supplies, Durable Medical Equipment, Appliances, Prosthetic Devices

The Plan will provide coverage for the purchase or rental of Plan-approved medical supplies/devices, prosthetic devices and durable medical equipment (DME). All supplies/equipment/devices must be required for the standard treatment of the illness or injury.

All Plan-approved supplies/equipment/devices must be medically necessary and are limited to the most cost-effective equipment. The Plan may authorize the purchase of an item if we determine the cost of purchasing an item would be less than the overall rental of the item. Supplies/equipment/devices must be prescribed by your qualified practitioner.

The reasonable cost of repairing an item is covered as long as this cost does not exceed the purchase of a new piece of equipment or device. Items that are replaced due to loss or negligence are not covered. Items that are replaced due to the availability of a newer or more efficient model are not covered unless the Plan determines otherwise. Repair or replacement is covered if due to normal growth processes or to a change in your physical condition due to illness or bodily injury.

Purchase or rental of durable medical equipment that is over $500 must be reviewed and pre-authorized by HMA’s Medical Review Coordinator.

The Plan covers:

• Casts, braces and supportive devices – Covered when used in the treatment of medical or surgical conditions in acute or convalescent stages or as immediate post-surgical care.

• Initial and replacement contact lenses, intraocular lenses, prescription lenses or standard frame glasses – Covered when required as a result of injury, illness or surgery, such as cataract, corneal transplant surgery or for the treatment of keratoconus.

• Rental of oxygen units used in the home – Covered for members with significant hypoxemia who are unresponsive to other forms of treatment. The benefit is limited to three months from the initial date of service unless there is clinical evidence of the need to continue.

• Orthotics – Limited to a maximum benefit of $300 every 24 months. Orthotics do not include prosthetic devices or childhood braces.

• Prosthetic devices – Covered supplies include prosthetic devices such as artificial limbs, breast implants following mastectomy, and artificial eyes.

• Maxillofacial prosthetic devices – Covered when considered medically necessary for the restoration and management of head and facial structures that cannot be replaced by living tissue. When head and facial structures are impaired due to disease, trauma, or developmental deformity. The devices must be needed to control or eliminate infection and pain and restore facial configuration and function.

• Medical devices surgically implanted in a body cavity to replace or aid the function of an internal organ.

• Medically necessary medical foods – Covered for supplementation or dietary replacement, including non-prescription elemental enteral formula for home use, when determined to be medically necessary for the treatment of severe intestinal malabsorption. Approval of these services will be based on criteria established by the Plan and in accordance with regulatory requirements. Medical foods are defined as foods that are formulated to be consumed or administered enterally under strict medical supervision for the treatment of inborn errors of metabolism including, but not limited to: phenylketonuria (PKU); homocystinuria, citrullinernia, maple syrup disease; and pyruvate dehydrogenase deficiency.

• Other medically necessary supplies – Covered when ordered by a qualified practitioner, including, but not limited to, ostomy supplies, supplies for radiologic procedures, prescribed needles, syringes and blood sugar check strips. You can purchase diabetes supplies through your Prescription Drug Care benefits or your provider's office.

• Durable medical equipment (DME) – Covered for rental of crutches, wheelchairs, hospital beds, or other therapeutic equipment when prescribed by a qualified practitioner, subject to the Plan’s durable medical equipment definition. Covered services for DME do not include items that are primarily and customarily used for a non-medical purpose or which are used for environmental control or enhancement (whether or not prescribed by a physician). All DME purchased in excess of $500 require prior authorization.

No other medical supplies, devices, prosthetic devices or DME are covered.

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Emergent/Urgent & Ambulance Services

Emergency services

Please see the Emergency and Urgent Care section.

Urgent care services

Please see the Emergency and Urgent Care section.

Ambulance

Services of a licensed ambulance company for transportation to the nearest medical facility where the required service is available, if other transportation would endanger the patient's health and the purpose of the transportation is not for personal or convenience reasons. Benefits for licensed air ambulance services will be provided to the nearest hospital equipped to render the necessary treatment, upon review of the Plan Supervisor. Out-of-area ambulance services to provide transportation to the nearest facility, or to a facility specified by the Plan.

We do NOT cover care cars, other medical transportation vehicles and other non-emergency medical transportation.

Diagnostic X-ray and Laboratory Services 

The Plan pays for inpatient and outpatient diagnostic pathology (laboratory), radiology (x-ray) tests and diagnostic procedures that include EMG, nerve conduction studies, nuclear medicine, pulmonary function, electrophysiology and other medically necessary diagnostic procedures when ordered by a qualified provider.

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Outpatient Rehabilitative Services

Short-term outpatient rehabilitative services are covered up to 30 visits per calendar year. Therapy is provided by physicians and/or licensed or registered therapists to restore or improve function due to illness or injury. Benefits are limited to covered services that can be expected to result in the significant improvement of your condition. Covered services are for outpatient physical, occupational and speech therapy.

The treatment must be part of a written treatment plan prescribed by a qualified provider. The Plan will NOT provide benefits for exercise programs; Rolfing, polarity therapy and similar therapies; and growth and cognitive therapies.

Outpatient Surgery, Chemotherapy & Radiation outpatient Therapy

Benefits are provided as shown on your Summary of Benefits and include services at a hospital or other facility. Covered services include, but are not limited to, services for a surgical procedure and regularly scheduled therapy such as chemotherapy, inhalation therapy, or radiation therapy as ordered by a qualified practitioner. The Plan may require that you obtain a second opinion for some elective procedures. If you do not obtain a second opinion when requested, we will not prior authorize the services and you will be fully responsible for payment.

Temporomandibular Joint (TMJ) Services

Benefits are provided for TMJ services from a Preferred Provider as shown on your Summary of Benefits. Enrolled out-of-area dependents may receive covered services from a non-Preferred Provider.

Covered services do NOT include dental or orthodontia services.

Treatment of specified dental services and restoration of head and facial structures

Covered services include restoration and management of head and facial structures, including teeth, dental implants and bridges, that cannot be replaced with living tissue and that are impaired because of trauma, disease or birth or development deformities. Benefits are covered as those services listed on your Summary of Benefits based upon the type of services received.

Conditions for receiving this benefit:

• All treatment, except emergency services, must be prior authorized by the Plan.

• Conditions related to trauma must be diagnosed within 30 days of injury and treatment must be completed within twelve months of the injury.

• Services must be prior authorized by the Plan and are only provided for members with complicating medical conditions.  Examples of these conditions include, but are not limited to, mental handicaps, physical disabilities, or a combination of medical conditions or disabilities that cannot be managed safely and efficiently in a dental office, or emotionally unstable, uncooperative, combative patients where treatment is extensive and impossible to accomplish in the office, or healthy children, under 7 years of age, with physician documented necessity.

Covered services do NOT include:

• Cosmetic services.

• Services rendered to improve a condition that falls within the normal range of such conditions.

• Orthodontia.

• Services to treat tooth decay, periodontal conditions and deficiencies in dental hygiene. Removal of impacted teeth.

• The making or repairing of dentures.

• Orthognathic surgery to shorten or lengthen the upper or lower jaw, unless related to a traumatic injury or to a neoplastic or degenerative disease.

• Services to treat TMJ joint disorder, except as specified in the covered TMJ services section above.

Outpatient hospitalization and anesthesia for dental services

Benefits for outpatient hospitalization and anesthesia for dental services are covered the same as relevant services listed on your Summary of Benefits.

Services must be prior authorized by the Plan and are only provided for members with complicating medical conditions. Examples of these conditions include, but are not limited to, mental handicaps, physical disabilities, or a combination of medical conditions or disabilities that cannot be managed safely and efficiently in a dental office.

All other dental services are excluded.

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Home health care

Home health visits are covered as shown on your Summary of Benefits. To be a covered benefit, a home health care provider must provide services at your home under a home health care treatment plan. Each visit by a person providing services under a home health care treatment plan, or each visit to evaluate the need for or development of a plan, is considered to be one home health care visit. Up to four consecutive hours in a 24-hour period of home health care service is considered to be one home health care visit. A home health care visit of more than four hours is considered one visit for every four hours or part thereof.

For home health care to be a covered benefit, your qualified provider needs to certify that the home health care services will be provided or coordinated by a state-licensed or Medicare-certified home health agency or certified rehabilitation agency. If you were hospitalized immediately prior to the start of your home health care, the home health plan must be initially approved by the same qualified practitioner who was the primary provider of the services you received during your hospitalization.

This benefit is not intended to provide custodial care but is provided for care in lieu of inpatient hospital, medical facility or skilled nursing facility care for patients who are homebound.

The following services will be considered eligible expenses:

• Part-time or intermittent nursing care by a registered nurse, a licensed vocational nurse or by a licensed practical nurse.

• Physical therapy by a licensed, registered or certified physical therapist.

• Speech therapy services by a licensed, registered or certified speech therapist.

• Occupational therapy services by a registered, certified or licensed occupational therapist.

• Nutritional guidance by a registered dietitian.

• Nutritional supplements such as diet substitutes administered intravenously or by enteral feeding.

• Respiratory therapy services by a certified inhalation therapist.

• Home health aide services by an aide who is providing intermittent care under the supervision of a registered nurse, physical therapist, occupational therapist or speech therapist. Such care includes ambulation and exercise, assistance with self-administered medications, reporting changes in your condition and needs, completing appropriate records.

• Medical supplies, drugs and medicines prescribed by a physician, and laboratory services normally used by a patient in a skilled nursing facility, medical facility or hospital, but only to the extent that they would have been covered under this Plan if the participant had remained in the hospital or medical facility.

• Services for Home Health Care must be pre-authorized by the UR Coordinator prior to services being rendered.

Home health care benefits do NOT include:

• Charges for mileage or travel time to and from your home.

• Wage or shift differentials for home health providers.

• Charges for supervision of home health providers.

• Services that consist principally of custodial care including, but not limited to, care for senile deterioration, mental deficiency, mental retardation or mental illness, or care of a chronic or congenital condition on a long-term basis.

• Services provided that are not otherwise covered under the Plan.

• Meals on Wheels or similar home delivered food services.

• Services performed by a member of the patient’s family or household.

• Supportive environmental materials such as handrails, ramps, telephones, air conditioners or similar appliance or device.

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Hospice care

Covered hospice care services are provided, as stated on your Summary of Benefits, for members who have a terminal illness and are expected to live six months or less. This determination needs to be certified by your qualified provider and determined by the Plan to be medically necessary. Hospice care services are limited to medical care that provides comfort and support for a dying person, usually in his or her home, but does not effect a cure. Covered services provided must be reasonable and necessary for the condition and symptoms being treated.

When the above criteria are met, the Plan will provide benefits for a full range of covered services that a certified hospice care program is required to include.

Covered services include:

• Nursing care provided by or under the supervision of a registered nurse.

• Medical social services provided by a medical social worker who is working under the direction of a physician. This may include counseling for the purpose of helping the patient and caregivers adjust to the approaching death.

• Services provided by your qualified practitioner or a physician associated with the hospice program

• Durable medical equipment, medical supplies and devices, including medications used primarily for the relief of pain and control of symptoms related to the terminal illness.

• Home health aide services for personal care, maintenance of a safe and healthy environment and general support for the goals of the plan of care; including a maximum of 120 hours of respite care to the primary care giver during a three-month period.

• Rehabilitation therapies (including physical, speech, occupational and respiratory therapies) provided for purposes of symptom control or to enable the patient to maintain activities of daily living and basic functional skills.

• Continuous home care during a period of crisis in which the patient requires skilled intervention to achieve palliation or management of acute medical symptoms.

• Benefits for hospice care services may be extended an additional six months in cases where a member is facing imminent death, or is entering a remission, and the member’s condition has been certified in writing by the attending physician.

No other services are covered under the hospice care benefit.

Podiatry/foot services

Covered services include the services provided by a podiatrist or other qualified practitioner and are covered as stated on your Summary of Benefits under the Physician/Provider Services section. Covered services include, but are not limited to, the fitting and follow-up exam for orthotics when required as a result of surgery, congenital defect or diabetes. Orthotics are covered as stated under the "Orthotics," section.

Covered services do NOT include routine foot care and the removal of corns or calluses, unless you have diabetes.

Reconstructive Breast Surgery

Medically necessary reconstructive breast surgery following a mastectomy is a covered benefit. This includes reconstruction of the involved breast following a mastectomy due to disease, illness or injury; surgery and construction of the other breast to produce a symmetrical appearance; and prosthesis and treatment of physical complications of all stages of mastectomy, including lymphedemas. A member receiving benefits for a medically necessary mastectomy who elects breast reconstruction after the mastectomy, will also receive coverage for:

• Reconstruction of the breast on which the mastectomy has been performed

• Surgery and reconstruction of the other breast to produce a symmetrical appearance

• Prostheses

• Treatment of physical complications of all stages of mastectomy, including lymphedemas.

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Cosmetic/Reconstructive Surgery

Reconstructive surgery that is incidental to or follows surgery resulting from trauma, infection or other diseases of the involved part is covered. The Plan also will provide covered services for the treatment of congenital disease or anomaly of a covered dependent child that has resulted in a defect. Benefits are covered as those services listed on your Summary of Benefits based upon the type of services received. All covered services must be prior authorized by the Plan.

Not covered: All other forms of cosmetic surgery, such as services and supplies that are applied to normal structures of the body for the purpose of improving or changing appearance or enhancing self-esteem, are excluded.

Inborn Errors

Covered services include services received for diagnosing, monitoring and controlling of Metabolism inborn errors of metabolism, including PKU, that involve amino acid, carbohydrate and fat metabolism. Covered services include clinical visits, biochemical analysis and medical foods used in the treatment of such disorders. See the"Medically Necessary Medical Foods," section, for coverage information on medical food supplies. Coverage is provided as shown on your Summary of Benefits based upon the type of services received.

Human organ/tissue transplants

Benefits for human organ and tissue transplants include covered services to theextent shown on your Summary of Benefits that are not experimental, investigational or for research purposes. Combined transplant services are limited to a $250,000 lifetime maximum.

Covered services consist of all phases of prior authorized treatment:

1. Evaluation;

2. Pre-transplant care;

3. Transplant and any donor covered services; and

4. Follow-up treatment, including any prescription drugs received relating to the transplant, are covered when provided within two years of the transplant procedure.

Covered services incurred by a live donor are provided under this benefit (to a m