Coventry Health Care of Louisiana, Inc.
http://www.chcla.com
Customer Service 1-800-341-6613
2015
Health Maintenance Organization (High and Standard Option)
IMPORTANT
• Rates: Back Cover
• Changes for 2015: Page 13
• Summary of benefits: Page 74
This plan’s health coverage qualifies as minimum essential coverage
and meets the minimum value standard for the benefits it provides. See
page 7 for details.
Serving: New Orleans
Enrollment in this plan is limited. You must live or work in our
geographic service area to enroll. See page 8 for requirements.
Enrollment codes for this Plan:
New Orleans area
BJ1 High Option – Self Only
BJ2 High Option – Self and Family
BJ4 Standard Option – Self Only
BJ5 Standard Option – Self and Family
RI 73-244
Important Notice from Coventry Health Care of Louisiana About
Our Prescription Drug Coverage and Medicare
The Office of Personnel Management (OPM) has determined that the Coventry Health Care of Louisiana's prescription drug
coverage is, on average, expected to pay out as much as the standard Medicare prescription drug coverage will pay for all
plan participants and is considered Creditable Coverage. This means you do not need to enroll in Medicare Part D and pay
extra for prescription drug coverage. If you decide to enroll in Medicare Part D later, you will not have to pay a penalty for
late enrollment as long as you keep your FEHB coverage.
However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and we will coordinate benefits
with Medicare.
Remember: If you are an annuitant and you cancel your FEHB coverage, you may not re-enroll in the FEHB Program.
Please be advised
If you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that’s as least as good
as Medicare’s prescription drug coverage, your monthly Medicare Part D premium will go up a least 1% per month for every
month that you did not have that coverage. For example, if you go 19 months without Medicare Part D prescription drug
coverage, your premium will always be at least 19 percent higher than what many other people pay. You will have to pay
this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the
Annual Coordinated Election Period (October 15 through December 7) to enroll in Medicare Part D.
Medicare’s Low Income Benefits
For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available.
Information regarding this program is available through the Social Security Administration (SSA) online at www.
socialsecurity.gov , or call the SSA at 1-800-772-1213 (TTY 1-800-325-0778).
You can get more information about Medicare prescription drug plans and the coverage offered in your area from these
places:
•Visit www.medicare.gov for personalized help,
•Call 1-800-MEDICARE (1-800-633-4227), TTY: (1-877-486-2048).
Table of Contents
Introduction ...................................................................................................................................................................................3
Plain Language ..............................................................................................................................................................................3
Stop Health Care Fraud! ...............................................................................................................................................................3
Preventing Medical Mistakes ........................................................................................................................................................4
FEHB Facts ...................................................................................................................................................................................7
No pre-existing condition limitation ...................................................................................................................................7
Minimum essential coverage (MEC) ..................................................................................................................................7
Minimum value standard ...................................................................................................................................................-1
Where you can get information about enrolling in the FEHB Program .............................................................................7
Types of coverage available to you and your family ..........................................................................................................7
Family member coverage ....................................................................................................................................................8
Children’s Equity Act ..........................................................................................................................................................8
When benefits and premiums start ......................................................................................................................................9
When you retire ...................................................................................................................................................................9
When FEHB coverage ends ................................................................................................................................................9
Upon divorce .....................................................................................................................................................................10
Temporary Continuation of Coverage (TCC) ...................................................................................................................10
Finding replacement coverage ..........................................................................................................................................10
Health Insurance Marketplace ..........................................................................................................................................10
Section 1. How this plan works ...................................................................................................................................................11
Your Rights .......................................................................................................................................................................12
Service Area ......................................................................................................................................................................12
Section 2. Changes for 2015 .......................................................................................................................................................13
Changes to All Options .....................................................................................................................................................10
Changes to High Option only ............................................................................................................................................10
Changes to Standard Option only .....................................................................................................................................10
Changes to High Deductible Health Plan only .................................................................................................................10
Section 3. How you get care .......................................................................................................................................................14
Identification cards ............................................................................................................................................................14
Where you get covered care ..............................................................................................................................................14
Plan providers .........................................................................................................................................................14
Plan facilities ...........................................................................................................................................................14
What you must do to get covered care ..............................................................................................................................14
Primary care ............................................................................................................................................................14
Specialty care ..........................................................................................................................................................14
Hospital care ...........................................................................................................................................................14
If you are hospitalized when your enrollment begins .............................................................................................15
You need prior Plan approval for certain services ............................................................................................................15
Inpatient hospital admission ...................................................................................................................................15
Other services ..........................................................................................................................................................15
How to request precertification for an admission or get prior authorization for Other services ......................................15
Non-urgent care claims ...........................................................................................................................................16
Urgent care claims ..................................................................................................................................................16
Concurrent care claims ...........................................................................................................................................16
Emergency inpatient admission ..............................................................................................................................17
If your treatment needs to be extended ...................................................................................................................17
1 2015 Coventry Health Care of Louisiana, Inc. Table of Contents
What happens when you do not follow the precertification rules when using non-network facilities .............................17
Circumstances beyond our control ..........................................................................................................................17
If you disagree with our pre-service claim decision .........................................................................................................17
To reconsider a non-urgent care claim ....................................................................................................................17
To reconsider an urgent care claim .........................................................................................................................17
To file an appeal with OPM ....................................................................................................................................18
Section 4. Your costs for covered services ..................................................................................................................................19
Copayments .......................................................................................................................................................................19
Cost-Sharing ......................................................................................................................................................................19
Deductible .........................................................................................................................................................................19
Coinsurance .......................................................................................................................................................................19
Your catastrophic protection out-of-pocket maximum .....................................................................................................19
Differences between our allowance and the bill ...............................................................................................................20
When Government facilities bill us ..................................................................................................................................20
Section 5. Benefits ......................................................................................................................................................................16
High and Standard Option Benefits Table of Contents .....................................................................................................21
Section 6. General exclusions – services, drugs and supplies we do not cover ..........................................................................58
Section 7. Filing a claim for covered services ............................................................................................................................59
Section 8. The disputed claims process .......................................................................................................................................61
Section 9. Coordinating benefits with other coverage ................................................................................................................64
When you have other health coverage ..............................................................................................................................65
TRICARE and CHAMPVA ..............................................................................................................................................64
Workers’ Compensation ....................................................................................................................................................64
Medicaid ............................................................................................................................................................................64
When other Government agencies are responsible for your care .....................................................................................64
When others are responsible for injuries ...........................................................................................................................64
When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) Coverage ........................................64
Clinical Trials ....................................................................................................................................................................65
When you have Medicare .................................................................................................................................................65
What is Medicare? ............................................................................................................................................................65
• Should I enroll in Medicare? ..............................................................................................................................66
• The Original Medicare Plan (Part A or Part B) ..................................................................................................66
• Tell us about your Medicare coverage ................................................................................................................67
• Medicare Advantage (Part C) .............................................................................................................................67
• Medicare prescription drug coverage (Part D) ...................................................................................................67
Section 10. Definitions of terms we use in this brochure ...........................................................................................................69
Section 11. Other Federal Programs ...........................................................................................................................................71
The Federal Flexible Spending Account Program - FSAFEDS ........................................................................................69
The Federal Employees Dental and Vision Insurance Program - FEDVIP ......................................................................70
The Federal Long Term Care Insurance Program - FLTCIP ............................................................................................70
Index ............................................................................................................................................................................................73
Summary of benefits for the High Option of Coventry Health Care of Louisiana 2015 ............................................................74
Summary of benefits for the Standard Option of Coventry Health Care of Louisiana 2015 ......................................................75
2 2015 Coventry Health Care of Louisiana, Inc. Table of Contents
Introduction
This brochure describes the benefits of Coventry Healthcare of Louisiana under our contract (CS 2050) with the United
States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. Customer service may
be reached at 1-800-341-6613 or through our website www.chcla.com. The address for administrative offices is:
Coventry Health Care Of Louisiana - 3838 North Causeway Blvd., Ste 3350 Metairie, La 70005
This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations,
and exclusions of this brochure. It is your responsibility to be informed about your health benefits.
If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self and
Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were
available before January 1, 2015, unless those benefits are also shown in this brochure.
OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2015 and changes are
summarized on page 9. Rates are shown at the end of this brochure.
Coverage under this plan qualifies as minimum essential coverage (MEC) and satisfies the Patient Protection and Affordable
Care Act's (ACA) individual shared responsibility requirement. Please visit the Internal Revenue Service (IRS) website at
www.irs.gov/uac/Questions-Answers-on-the-individual-Shared-Responsibility-Provision for more information on the
individual requirement for MEC.
The ACA establishes a minimum value for the standard of benefits of a health plan. The minimum value standard is 60%
(actuarial value). The health coverage of this plan does meet the minimum value standard for the benefits the plan provides.
Plain Language
All FEHB brochures are written in plain language to make them easy to understand. Here are some examples.
•Except for necessary technical terms, we use common words. For instance, “you” means the enrollee or family member,
“we” means Coventry Health Care of Louisiana
.
•We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United States
Office of Personnel Management. If we use others, we tell you what they mean.
•Our brochure and other FEHB plans’ brochures have the same format and similar descriptions to help you compare plans.
Stop Health Care Fraud!
Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits Program
premium.
OPM’s Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program
regardless of the agency that employs you or from which you retired.
Protect Yourself From Fraud – Here are some things that you can do to prevent fraud:
•Do not give your plan identification (ID) number over the telephone or to people you do not know, except to your doctor,
other provider, or authorized plan or OPM representative.
•Let only the appropriate medical professionals review your medical record or recommend services.
•Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to
get it paid.
•Carefully review explanations of benefits (EOBs) that you receive from us.
•Periodically review your claim history for accuracy to ensure we have not been billed for services that you did not receive.
3 2015 Coventry Health Care of Louisiana, Inc. Introduction/Plain Language/Advisory
•Please review your claims history periodically for accuracy to ensure services are not being billed to your accounts that
were never rendered.
•Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.
•If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or
misrepresented any information, do the following:
- Call the provider and ask for an explanation. There may be an error.
- If the provider does not resolve the matter, call us at 800-341-6613 and explain the situation.
- If we do not resolve the issue:
CALL - THE HEALTH CARE FRAUD HOTLINE
877-499-7295
OR go to www.opm.gov/oig
You can also write to:
United States Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington, DC20415-1100
•Do not maintain as a family member on your policy:
- Your former spouse after a divorce decree or annulment is final (even if a court order stipulates otherwise)
- Your child age 26 or over (unless he/she was disabled and incapable of self-support prior to age 26).
•If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed, with
your retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under
Temporary Continuation of Coverage.
•Fraud or intentional misrepresentation of material face is prohibited under the Plan. You can be prosecuted for fraud and
your agency may take action against you. Examples of fraud include, falsifying a claim to obtain FEHB benefits, trying to
or obtaining service or coverage for yourself or for someone who is no longer eligible.
•If your enrollment continues after you are no longer eligible for coverage (i.e. you have separated from Federal service)
and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not
paid. You may be billed by your provider for services received. You may be prosecuted for fraud for knowingly using
health insurance benefits for which you have not paid premiums. It is your responsibility to know when you or a family
member is no longer eligible to use your health insurance coverage.
Preventing Medical Mistakes
An influential report from the Institute of Medicine estimates that up to 98,000 Americans die every year from medical
mistakes in hospitals alone. That’s about 3,230 preventable deaths in the FEHB Program a year. While death is the most
tragic outcome, medical mistakes cause other problems such as permanent disabilities, extended hospital stays, longer
recoveries, and even additional treatments. By asking questions, learning more and understanding your risks, you can
improve the safety of your own health care, and that of your family members. Take these simple steps:
1. Ask questions if you have doubts or concerns.
•Ask questions and make sure you understand the answers.
•Choose a doctor with whom you feel comfortable talking.
4 2015 Coventry Health Care of Louisiana, Inc. Introduction/Plain Language/Advisory
•Take a relative or friend with you to help you ask questions and understand answers.
2. Keep and bring a list of all the medicines you take.
•Bring the actual medicines or give your doctor and pharmacist a list of all the medicines and dosage that you take,
including non-prescription (over-the-counter) medicines and nutritional supplements.
•Tell your doctor and pharmacist about any food, and other allergies you have, such as to latex.
•Ask about any risks or side effects of the medication and what to avoid while taking it. Be sure to write down what your
doctor or pharmacist says.
•Make sure your medicine is what the doctor ordered. Ask the pharmacist about your medicine if it looks different than you
expected.
•Read the label and patient package insert when you get your medicine, including all warnings and instructions.
•Know how to use your medicine. Especially note the times and conditions when your medicine should and should not be
taken.
•Contact your doctor or pharmacist if you have questions.
3. Get the results of any test or procedure.
•Ask when and how you will get the results of tests or procedures.
•Don’t assume the results are fine if you do not get them when expected, be it in person, by phone, or by mail.
•Call your doctor and ask for your results.
•Ask what the results mean for your care.
4. Talk to your doctor about which hospital is best for your health needs.
•Ask your doctor about which hospital has the best care and results for your condition if you have more than one hospital to
choose from to get the health care you need.
•Be sure you understand the instructions you get about follow-up care when you leave the hospital.
5. Make sure you understand what will happen if you need surgery.
•Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.
•Ask your doctor, “Who will manage my care when I am in the hospital?”
•Ask your surgeon:
- "Exactly what will you be doing?"
- "About how long will it take?"
- "What will happen after surgery?"
- "How can I expect to feel during recovery?"
•Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reaction to anesthesia, and any medications or
nutritional supplements you are taking.
Patient Safety Links
- www.ahrq.gov/consumer/ The Agency for Healthcare Research and Quality makes available a wide-ranging list of
topics not only to inform consumers about patient safety but to help choose quality health care providers and improve
the quality of care you receive.
- www.npsf.org. The National Patient Safety Foundation has information on how to ensure safer health care for you and
your family.
5 2015 Coventry Health Care of Louisiana, Inc. Introduction/Plain Language/Advisory
- www.talkaboutrx.org/ The National Council on Patient Information and Education is dedicated to improving
communication about the safe, appropriate use of medicines.
- www.leapfroggroup.org. The Leapfrog Group is active in promoting safe practices in hospital care.
- www.ahqa.org. The American Health Quality Association represents organizations and health care professionals
working to improve patient safety.
Never Events
When you enter a hospital for treatment of one medical problem, you don't expect to leave with additional injuries, infections
or other serious conditions that occur during the course of your stay. Although some of these complications may not be
avoidable, too often patients suffer from injuries or illnesses that could have been prevented if the hospital had taken proper
precautions.
We have a benefit payment policy that encourages hospitals to reduce the likelihood of hospital-acquired conditions such as
certain infections, sever bedsores and fractures; and reduce medical errors that should never happen. These conditions and
errors are called "Never Events". When a Never Event occurs, neither your FEHB plan nor you will incur cost to correct the
medical error.
You will not be billed for inpatient services related to treatment of specific hospital acquired conditions or for inpatient
services needed to correct Never Events, if you use Coventry Health Care of Louisiana preferred providers. This policy
helps to protect you from preventable medical errors and improve the quality of care you receive.
6 2015 Coventry Health Care of Louisiana, Inc. Introduction/Plain Language/Advisory
FEHB Facts
Coverage information
We will not refuse to cover the treatment of a condition you had before you enrolled in
this Plan solely because you had the condition before you enrolled.
• No pre-existing
condition limitation
Coverage under this plan qualifies as minimum essential coverage (MEC) and satisfies the
Patient Protection and Affordable Care Act's (ACA) individual shared responsibility
requirement. Please visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/
Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more
information on the individual requirement for MEC.
• Minimum essential
coverage (MEC)
Our health coverage meets the minimum value standard of 60% established by the ACA.
This means that we provide benefits to cover at least 60% of the total allowed costs of
essential health benefits. The 60% is an actuarial value, your specific out-of-pocket costs
are detetermined as explained in this brochure.
• Minimum value
standard
See www.opm.gov/insure/health for enrollment information as well as:
• Information on the FEHB Program and plans available to you
• A health plan comparison tool
• A list of agencies that participate in Employee Express
• A link to Employee Express
• Information on and links to other electronic enrollment systems
Also, your employing or retirement office can answer your questions, and give you a
Guide to Federal Benefits,
brochures for other plans, and other materials you need to
make an informed decision about your FEHB coverage. These materials tell you:
• When you may change your enrollment
• How you can cover your family members
• What happens when you transfer to another Federal agency, go on leave without pay,
enter military service, or retire
• What happens when your enrollment ends
• When the next Open Season for enrollment begins.
We don’t determine who is eligible for coverage and, in most cases, cannot change your
enrollment status without information from your employing or retirement office. For
information on your premium deductions, you must also contact your employing or
retirement office.
• Where you can get
information about
enrolling in the FEHB
Program
Self Only coverage is for you alone. Self and Family coverage is for you, your spouse,
and your dependent children, including any foster children authorized for coverage by
your employing agency or retirement office. Under certain circumstances, you may also
continue coverage for a disabled child 26 years of age or older who is incapable of self-
support.
If you have a Self Only enrollment, you may change to a Self and Family enrollment if
you marry, give birth, or add a child to your family. You may change your enrollment 31
days before to 60 days after that event. The Self and Family enrollment begins on the first
day of the pay period in which the child is born or becomes an eligible family member.
When you change to Self and Family because you marry, the change is effective on the
first day of the pay period that begins after your employing office receives your
enrollment form; benefits will not be available to your spouse until you marry.
• Types of coverage
available to you and
your family
7 2015 Coventry Health Care of Louisiana, Inc.
Your employing or retirement office will not notify you when a family member is no
longer eligible to receive benefits, nor will we. Please tell us immediately of changes in
family member status, including your marriage, divorce, annulment, or when your child
reaches age 26.
If you or one of your family members is enrolled in one FEHB plan, that person may
not be enrolled in or covered as a family member by another FEHB plan.
If you have a qualifying life event (QLE) - such as marriage, divorce, or the birth of a
child-outside of the Federal Benefits Open Season, you may be eligible to enroll in the
FEHB Program, change your enrollment, or cancel coverage. For a complete list of
QLEs, visit the FEHB website at www.opm.gov/healthcare-insurance/life-events. If you
need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/
payroll office, or retirement office.
Family members covered under your Self and Family enrollment are your spouse
(including a valid common law marriage) and children as described in the chart below.
ChildrenCoverage
Natural children, adopted children, and
stepchildren
Natural, adopted children and stepchildren
(including qualified children of same-sex
domestic partners in certain states) are
covered until their 26th birthday.
Foster children Foster children are eligible for coverage
until their 26th birthday if you provide
documenation of your regular and
substantial support of the child and sign a
certification stating that your foster child
meets all the requirements. Contact your
human resources office or retirement system
for additional information.
Children Incapable fo self-support Children who are incapable of self-support
because of a mental or physical disability
that began before age 26 are eligible to
continue coverage. Contact your human
resources office or retirement system for
additional information.
Married children Married children (but NOT their spouse or
their own children) are covered until their
26th birthday.
Children with or eligible for employer-
provided health insurance
Children who are eligible for or have their
own employer-provided health insurance are
covered until their 26th birthday.
You can find additional information at www.opm.gov/insure.
• Family member
coverage
OPM has implemented the Federal Employees Health Benefits Children’s Equity Act of
2000. This law mandates that you be enrolled for Self and Family coverage in the FEHB
Program, if you are an employee subject to a court or administrative order requiring you
to provide health benefits for your child(ren).
If this law applies to you, you must enroll for Self and Family coverage in a health plan
that provides full benefits in the area where your children live or provide documentation
to your employing office that you have obtained other health benefits coverage for your
children. If you do not do so, your employing office will enroll you involuntarily as
follows:
• Children’s Equity Act
8 2015 Coventry Health Care of Louisiana, Inc.
• If you have no FEHB coverage, your employing office will enroll you for Self and
Family coverage in the Blue Cross and Blue Shield Service Benefit Plan’s Basic
Option;
• If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves
the area where your children live, your employing office will change your enrollment
to Self and Family in the same option of the same plan; or
• If you are enrolled in an HMO that does not serve the area where the children live,
your employing office will change your enrollment to Self and Family in the Blue
Cross and Blue Shield Service Benefit Plan’s Basic Option.
As long as the court/administrative order is in effect, and you have at least one child
identified in the order who is still eligible under the FEHB Program, you cannot cancel
your enrollment, change to Self Only, or change to a plan that doesn’t serve the area in
which your children live, unless you provide documentation that you have other coverage
for the children. If the court/administrative order is still in effect when you retire, and you
have at least one child still eligible for FEHB coverage, you must continue your FEHB
coverage into retirement (if eligible) and cannot cancel your coverage, change to Self
Only, or change to a plan that doesn’t serve the area in which your children live as long as
the court/administrative order is in effect. Contact your employing office for further
information.
The benefits in this brochure are effective January 1. If you joined this Plan during Open
Season, your coverage begins on the first day of your first pay period that starts on or after
January 1. If you changed plans or plan options during Open Season and you receive
care between January 1 and the effective date of coverage under your new plan or
option, your claims will be paid according to the 2015 benefits of your old plan or
option. However, if your old plan left the FEHB Program at the end of the year, you are
covered under that plan’s 2014 benefits until the effective date of your coverage with your
new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any
other time during the year, your employing office will tell you the effective date of
coverage.
If your enrollment continues after you are no longer eligible for coverage, (i.e. you have
separated from Federal service) and premiums are not paid, you will be responsible for all
benefits paid during the period in which premiums were not paid. You may be billed for
services received directly from your provider. You may be prosecuted for fraud for
knowingly using health insurance benefits for which you have not paid premiums. It is
your responsibility to know when you or a family member are no longer eligible to use
your health insurance coverage.
• When benefits and
premiums start
When you retire, you can usually stay in the FEHB Program. Generally, you must have
been enrolled in the FEHB Program for the last five years of your Federal service. If you
do not meet this requirement, you may be eligible for other forms of coverage, such as
Temporary Continuation of Coverage (TCC).
• When you retire
When you lose benefits
You will receive an additional 31 days of coverage, for no additional premium, when:
• Your enrollment ends, unless you cancel your enrollment, or
• You are a family member no longer eligible for coverage.
Any person covered under the 31 day extension of coverage who is confined in a hospital
or other institution for care or treatment on the 31
st
day of the temporary extension is
entitled to continuation of the benefits of the Plan during the continuance of the
confinement but not beyond the 60
th
day after the end of the 31 day temporary extension.
• When FEHB coverage
ends
9 2015 Coventry Health Care of Louisiana, Inc.
You may be eligible for spouse equity coverage or Temporary Continuation of Coverage
(TCC), or a conversion policy (a non-FEHB individual policy.)
If you are divorced from a Federal employee, Tribal employee, or an annuitant, you may
not continue to get benefits under your former spouse’s enrollment. This is the case even
when the court has ordered your former spouse to provide health coverage for you.
However, you may be eligible for your own FEHB coverage under either the spouse
equity law or Temporary Continuation of Coverage (TCC). If you are recently divorced or
are anticipating a divorce, contact your ex-spouse’s employing or retirement office to get
RI 70-5, the
Guide to Federal Benefits for Temporary Continuation of Coverage and
Former Spouse Enrollees,
or other information about your coverage choices. You can also
download the guide from OPM’s Website, www.opm.gov/insure.
• Upon divorce
If you leave Federal service, Tribal employer or if you lose coverage because you no
longer qualify as a family member, you may be eligible for Temporary Continuation of
Coverage (TCC). The Affordable Care Act (ACA) did not eliminate TCC or change the
TCC rules. For example, you can receive TCC if you are not able to continue your FEHB
enrollment after you retire, if you lose your Federal or Tribal job, if you are a covered
dependent child and you turn 26.
You may not elect TCC if you are fired from your Federal or Tribal job due to gross
misconduct.
Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-5, the
Guide to
Federal Benefits for Temporary Continuation of Coverage and Former Spouse Enrollees,
from your employing or retirement office or from www.opm.gov/healthcare-insurance/
healthcare/plan-information/guides. It explains what you have to do to enroll.
Alternatively, you can buy coverage through the Health Insurance Marketplace where,
depending on your income, you could be eligible for a new kind of tax credit that lowers
your monthly premium. Visit www.HealthCare.gov to compare plans and see what your
premium, deductible, and out-of-pocket costs would be before you make a decision to
enroll. Finally, if you qualify for coverage under another group health plan (such as your
spouse's plan), you may be able to enroll in that plan, as long as you apply within 30 days
of losing FEHB Program coverage.
We also want to inform you that the Affordable Care Act (ACA) did not eliminate TCC or
change the TCC rules.
• Temporary
Continuation of
Coverage (TCC)
In lieu of offering a non-FEHB plan for conversion purposes, we will assist you, as we
would assist you in obtaining a plan conversion policy, in obtaining health benefits
coverage inside or outside the Affordable Care Act's Health Insurance Marketplace. For
assistance in finding coverage, please contact us at 1-800-341-6613 or visit our website at
www.chcla.com.
• Finding replacement
coverage
If you would like to purchase health insurance through the Affordable Care Act's Health
Insurance Marketplace, please visit www.HealthCare.gov. This is a website provided by
the U.S. Department of Health and Human Services that provides up-to-date information
on the Marketplace.
• Health Insurance
Marketplace
10 2015 Coventry Health Care of Louisiana, Inc.
Section 1. How this plan works
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other
providers that contract with us. These Plan providers coordinate your health care services. The Plan is solely responsible for
the selection of these providers in your area. Contact the Plan for a copy of their most recent provider directory. We give
you a choice of enrollment in a High Option or Standard Option.
HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in
addition to treatment for illness and injury. Our providers follow generally accepted medical practice when prescribing any
course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You pay only the
copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from non-Plan
providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan’s benefits, not because a particular provider is available. You
cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician, hospital, or
other provider will be available and/or remain under contract with us.
General features of our High and Standard Options
We have Open Access benefits
Our HMO offers Open Access benefits. This means you can receive covered services from a participating provider without a
required referral from your primary care physician or by another participating provider in the network.
How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan
providers accept negotiated payment from us, and you will only be responsible for your deductible, copayments or
coinsurance.
If you have any questions regarding choosing a doctor, please call our Member Services Department at 800-341-6613.
The Plan’s provider directory lists primary care doctors (generally family practitioners, pediatricians, and internists) with
their locations and phone numbers, and notes whether or not the doctor is accepting new patients. Directories are updated on
a regular basis and are available at the time of enrollment or upon request by calling the Member Services Department at
800-341-6613; you can also find out if your doctor participates with this Plan by calling this number. If you are interested in
receiving care from a specific provider who is listed in the directory, call the provider to verify that he or she still participates
with the Plan and is accepting new patients. Important note: When you enroll in this Plan, services (except for emergency
benefits) are provided through the Plan’s delivery system; the continued availability and/or participation of any one doctor,
hospital, or other provider, cannot be guaranteed. You can also find providers by visiting the website www.chcla.com, click
members and select provider search for CHC louisiana.
If you are receiving services from a doctor who leaves the Plan, the Plan will pay for covered services until the Plan can
arrange with you for you to be seen by another participating doctor.
Preventive care services
Preventive care services are generally covered with no cost-sharing and are not subject to copayments, deductibles or annual
limits when received from a network provider.
11 2015 Coventry Health Care of Louisiana, Inc. Section 1
Your Rights
OPM requires that all FEHB plans provide certain information to their FEHB members. You may get information about us,
our networks, providers, and facilities. OPM’s FEHB Web site (www.opm.gov/insure) lists the specific types of information
that we must make available to you. Some of the required information is listed below.
•Coventry Health Care is a Federally qualified health maintenance organization (HMO)
•Profit status – For profit
If you want more information about us, call 800-341-6613, or write to Coventry Health Care of Louisiana, Inc., 3838 North
Causeway Blvd., Suite 3350, Metairie, LA 70002. You may also contact us by fax at 504-834-2694 or visit our website at
www.chcla.com.
Your Medical and claims records are confidential
We will keep your medical and claims records confidential. Please note that we may disclose your medical and claims
information (including your prescription drug utilization) to any of your treating physicans or dispensing pharmacies.
Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our service area is
the following parishes:
New Orleans service area: Jefferson, Orleans, Plaquemines, St. Bernard, St. Charles, and St. Tammany.
Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will
pay only for emergency care benefits. We will not pay for any other health care services out of our service area unless the
services have prior plan approval.
If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live
out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service
plan or an HMO that has agreements with affiliates in other areas. If you or a family member move, you do not have to wait
until Open Season to change plans. Contact your employing or retirement office.
12 2015 Coventry Health Care of Louisiana, Inc. Section 1
Section 2. Changes for 2015
Do not rely only on these change descriptions; this Section is not an official statement of benefits. For that, go to Section 5
Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a
clarification that does not change benefits.
NO CHANGES HAVE BEEN MADE TO YOUR PLAN FOR 2015
Standard Option
Applied Behavioral Analysis (ABA) services for the treatment of Autism Spectrum Disorder is covered subject to a $55
copay per visit.
High Option
Applied Behavioral Analysis (ABA) services for the treatment of Autism Spectrum Disorder is covered subject to a $45
copay per visit.
13 2015 Coventry Health Care of Louisiana, Inc. Section 2
Section 3. How you get care
We will send you an identification (ID) card when you enroll. You should carry your ID
card with you at all times. You must show it whenever you receive services from a Plan
provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use
your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment
confirmation (for annuitants), or your electronic enrollment system (such as Employee
Express) confirmation letter.
If you do not receive your ID card within 30 days after the effective date of your
enrollment, or if you need replacement cards, call us at 800-341-6613 or write to us at
3838 North Causeway Boulevard, Suite 3350, Metairie, LA 70002. You may also request
replacement cards through our Website at www.chcla.com
Identification cards
You get care from “Plan providers” and “Plan facilities.” You will only pay copayments,
deductibles, and/or coinsurance, if you use our Open Access program you can receive
covered services from a participating provider without a required referral from your
primary care physician or by another participating provider in the ntwork.
Where you get covered
care
Plan providers are physicians and other health care professionals in our service area that
we contract with to provide covered services to our members. We credential Plan
providers according to national standards.
We list Plan providers in the provider directory, which we update periodically. The list is
also on our Website.
• Plan providers
Plan facilities are hospitals and other facilities in our service area that we contract with to
provide covered services to our members. We list these in the provider directory, which
we update periodically. The list is also on our Website.
• Plan facilities
It depends on the type of care you need. What you must do to get
covered care
Coventry does not require you to select a primary care physician. • Primary care
You may see a Specialist in the network without a referral. Your Specialist may have to
get an authorization or approval from us before treatment. Here are some things you
should know about specialty care:
If you have a chronic and disabling condition and lose access to your specialist because
we:
• terminate our contract with your specialist for other than cause;
• drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in
another FEHB program plan; or
• reduce our service area and you enroll in another FEHB plan;
you may be able to continue seeing your specialist for up to 90 days after you receive
notice of the change. Contact us, or if we drop out of the Program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose access to your
specialist based on the above circumstances, you can continue to see your specialist until
the end of your postpartum care, even if it is beyond the 90 days.
• Specialty care
Your Plan primary care physician or specialist will make necessary hospital arrangements
and supervise your care. This includes admission to a skilled nursing or other type of
facility.
• Hospital care
14 2015 Coventry Health Care of Louisiana, Inc. Section 3
We pay for covered services from the effective date of your enrollment. However, if you
are in the hospital when your enrollment in our Plan begins, call our customer service
department immediately at 800-341-6613. If you are new to the FEHB Program, we will
arrange for you to receive care and provide benefits for your covered services while you
are in the hospital beginning on the effective date of your coverage.
If you changed from another FEHB plan to us, your former plan will pay for the hospital
stay until:
• you are discharged, not merely moved to an alternative care center;
• the day your benefits from your former plan run out; or
• the 92
nd
day after you become a member of this Plan, whichever happens first.
These provisions apply only to the benefits of the hospitalized person. If your plan
terminates participation in the FEHB Program in whole or in part, or if OPM orders an
enrollment change, this continuation of coverage provision does not apply. In such cases,
the hospitalized family member’s benefits under the new plan begin on the effective date
of enrollment.
• If you are hospitalized
when your enrollment
begins
Since your primary care physician arranges most referrals to specailists and inpatient
hospitalization, the pre-service claim approval process only applies to care shown under
Other services.
You need prior Plan
approval for certain
services
Precertification is the process by which - prior to your inpatient hospital admission - we
evaluate the medical necessity of your proposed stay and the number of days required to
treat your condition.
• Inpatient hospital
admission
Your primary care physician has authority to refer you to most services. For certain
services, however, your physician must obtain prior approval from us. Before giving
approval, we consider if the service is covered, medically necessary, and follows generally
accepted medical practice. You must obtain prior authorization for for certain services,
such as, but not limited to inpatient hospital services, outpatient surgeries/treatments,
skilled nursing facilities, home health services, durable medical equipment, certain
diagnostic tests and subacute care also require approval of the utilization review
department before the services are initiated.
For certain services your physician must obtain approval from us. Before giving approval,
we consider if the service is covered, medically necessary, and follows generally accepted
medical practice.
We call this review and approval process prior authorization. Your physician must obtain
prior authorization.
Your physician must get the Plan’s approval before sending you to a hospital, or
recommended follow-up care. Before giving approval, we consider if the service is
medically necessary, and if it follows generally accepted medical practice.
If you obtain services from a specialist, hospital or other health care provider, the services
will be covered only if medically necessary and authorized, except in the case of
emergency medical services and urgent care.
• Other services
First, your physican, your hospital, you, or your representative, must call us at
1-800-341-6613 before admission or services requiring prior authorization are rendered.
Next, provide the following information:
• enrollee's name and Plan indentification number;
• patient's name, birth date, identification number and phone number;
• reason for hospitalization, proposed treatment, or surgery;
• How to request
precertification for an
admission or get prior
authorization for
Other services
15 2015 Coventry Health Care of Louisiana, Inc. Section 3
• name and phone number of admitting physician;
• name of hospital or facility; and
• number of days requested for hospital stay.
For non-urgent care claims, we will then tell the physician and/or hospital the number of
approved inpatient days, or the care that we approve for other services that must have
prior authorization. We will make our decision within 15 days of receipt of the pre-
service claim. If matters beyond our control require an extension of time, we may take up
to an additional 15 days for review and we will notify you of the need for an extension of
time before the end of the original 15 day period. Our notice will include the
circumstances underlying the request for the extension and the date when a decision is
expected.
If we need an extension because we have not received necessary informatin from you, our
notice will describe the specific information required and we will allow you up to 60 days
from the receipt of the ntoice to provide this information.
• Non-urgent care
claims
If you have an urgent care claim (i.e., when waiting for the regular time limit for your
medical care or treatment could seriously jeopardize your life, health, or ability to regain
maximum function or in the opinion of a physician with knowledge of your medical
condition, would subject you to severe pain that cannot be adequately managed without
this care or treatment), we will expedite our review and notify you of our decision within
72 hours. If you request that we review your claim as an urgent care claim, we will
review the documentation you provide and decide whether it is an urgent care claim by
applying the judgment of a prudent layperson who possesses an average knowledge of
health and medicine.
If you fail to provide sufficient information, we will contact you within 24 hours after we
receive the claim to provide notice of the specific information we need to complete our
review of the claim. We will allow you up to 48 hours from the receipt of this notice to
provide the necessary information. We will make our decision on the claim within 48
hours of (1) the time we received the additional information or (2) to end of the time
frame, whichever is earlier.
We may provide our decision orally within these time frames, but we will follow up with
written or electronic notification within three days of oral notification.
You may request that your urgent care claim on appeal be reviewed simulaneously by us
and OPM. Please let us know that you would like a simultaneous review of your urgent
care claim by OPM either in writing at the time you appeal our initial decision, or by
calling us at 1-800-341-6613. You may also call OPM's Health Insurance (3) at (202)
606-0737 between 8 a.m. and 5 p.m. Eastern Time to ask for the simultaneous review. We
will cooperate with OPM so they can quickly review your claim on appeal. In addition, if
you did not indicate that your claim was a claim for urgent care, call us at
1-800-341-6613. If it is determined that your claim is an urgent care claim, we will
expedite our review (if we have not yet responded to your claim).
• Urgent care claims
A concurrent care claim involves care provided over a period of time or over a number of
treatments. We will treat any reduction or termination of our pre-approved course of
treatment before the end of the approved period of time or number of treatments as an
appealable decision. This does not include reduction or termination due to benefit
changes or if your enrollment ends. If we believe a reduction or termination is warranted
we will allow you sufficient time to appeal and obtain a decision from us before the
reduction or termination takes effect.
• Concurrent care
claims
16 2015 Coventry Health Care of Louisiana, Inc. Section 3
If you request an extension of an ongoing course of treatment at least 24 hours prior to the
expiration of the approved time period and this is also an urgent care claim, then we ill
make a decision within 24 hours after we receive the claim.
If you have an emergency admission due to a condition that you reasonably believe puts
your life in danger or could cause serious damage to bodily function, you, your
representative, the physician, or the hospital must telephone us within two business days
following the day of the emergency admission, even if you have been discharged from the
hospital.
• Emergency inpatient
admission
If you request an extension of an ongoing course of treatment at least 24 hours prior to the
expiration of the approved time period and this is also an urgent care claim, then we will
make a decision within 24 hours after we receive the claim.
If your treatment needs
to be extended
Claims that require precertification, prior approval, or a referral and where failure to
obtain precertification, prior approval, or a referral results in a reduction of benefits.
What happens when you
do not follow the
precertification rules
when using non-network
facilities
Under certain extraordinary circumstances, such as natural disasters, we may have to
delay your services or we may be unable to provide them. In that case, we will make all
reasonable efforts to provide you with the necessary care.
Circumstances beyond
our control
If you have a pre-service claim and you do not agree with our decision regarding
precertification of an inpatient admission or prior approval of other services, you may
request a review in accord with the procedures detailed below.
If you have already received the service, supply, or treatment, then you have a post-
service claim and must to follow the entire disputed claims process detailed in Section 8.
If you disagree with our
pre-service claim decision
Within 6 months of our initial decision, you may ask us in writing to reconsider our initial
decision. Follow Step 1 of the disputed claims process detailed in Section 8 of this
brochure.
In the case of a pre-service claim and subject to a request for additional information, we
have 30 days from the date we receive your written request for reconsideration to
1. Precertify your hospital stay or if applicable, arrange for the health care provider to give
you the care or grant your request for prior approval for a service, drug, or supply; or
2. Ask you or your provider for more information.
You or your provider must send the information so that we recieve it within 60 days of our
request. We will then decide within 30 more days.
If we do not receive the information within 60 days we will decide within 30 days of the
date the information was due. We will base our decision on the information we already
have. We will write to you with our decision.
3. Write to you and maintain our denial.
• To reconsider a non-
urgent care claim
In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial
decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of
the disputed claims process detailed in Section 8 of this brochure.
Unless we request additional information, we will notify you of our decision within 72
hours after receipt of your reconsideration request. We will expedite the review process,
which allows oral or written requests for appeals and the exchange of information by
telephone, electronic mail, facsimile, or other expeditious methods.
• To reconsider an
urgent care claim
17 2015 Coventry Health Care of Louisiana, Inc. Section 3
After we reconsider your pre-service claim, if you do not agree with our decision, you
may ask OPM to review it by following Step 3 of the disputed claims process detailed in
Section 8 of this brochure.
• To file an appeal with
OPM
18 2015 Coventry Health Care of Louisiana, Inc. Section 3
Section 4. Your costs for covered services
This is what you will pay out-of-pocket for covered care:
Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g. deductible,
coinsurance, and copayments) for the covered care you receive.
Cost-Sharing
A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc.,
when you receive services.
High Option: Example: when you see your primary care physician, you pay a $25
copayment per office visit.
Copayments
A deductible is a fixed expense you must incur for certain covered services and supplies
before we start paying benefits for them. Copayments do not count toward the
deductible.
High Option: The calendar year deductible amount is $500 for individual and $1,000 for
family coverage.
Standard Option: The calendar year deductible amount is $1,000 for individual and
$2,000 for family coverage.
Note: If you change plans during Open Season, you do not have to start a new deductible
under your old plan between January 1 and the effective date of your new plan. If you
change plans at another time during the year, you must begin a new deductible under your
new plan.
Deductible
Coinsurance is the percentage of our allowance that you must pay for your care.
Coinsurance does not begin until you have met your calendar year deductible.
High Option: Example: you pay 50% of our allowance for infertility diagnostic testing.
Standard Option: Example: you pay 30% of our allowance for outpatient surgery.
Note: If your provider routinely waives (does not require you to pay) your copayments,
deductibles, or coinsurance, the provider is misstating the fee and may be violating the
law. In this case, when we calculate our share, we will reduce the provider's fee by the
amount waived.
For example, if your physician ordinarily charges $100 for a service but routinely waives
your 15% coinsurance, the actual charge is $70. We will pay $59.50 (85% of the acutal
charge of $70).
Coinsurance
High Option: After your deductible, coinsurance and all copayments total $3,000 for self
only or $6,000 per family enrollment in any calendar year, you do not have to pay any
more for covered services. Certain benefits have maximums different from the out-of-
pocket maximum, including, but not limited to:
• Durable Medical Equipment
• Infertility Diagnostic Testing
Be sure to keep accurate records of your deductible, copayments and coinsurance since
you are responsible for informing us when you reach the maximum.
Standard Option: After your deductible and coinsurance and all copayments total $4,000
per person or $8,000 per family enrollment in any calendar year, you do not have to pay
any more for covered services. Certain benefits have maximums different from the out-
of-pocket maximum, including, but not limited to:
• Durable Medical Equipment
Your catastrophic
protection out-of-pocket
maximum
19 2015 Coventry Health Care of Louisiana, Inc. Section 4
• Infertility Diagnostic Testing
Be sure to keep accurate records of your deductible, copayments, and coinsurances since
you are responsible for informing us when you reach the maximum.
In-network providers agree to limit what they will bill you. Because of that, when you
use a network provider, your share of covered charges consists only of your deductible
and coinsurance or copayment. Here is an example about coinsurance: You see a network
physician who charges $150, but our allowance is $100. If you have met your deductible,
you are only responsible for your coinsurance. That is, you pay just – 15% of our $100
allowance ($15). Because of the agreement, your network physician will not bill you for
the $50 difference between our allowance and his bill.
Differences between our
allowance and the bill
Facilities of the Department of Veterans affairs, the Department of Defense and the Indian
Health Services are entitled to seek reimbursement from us for certain services and
supplies they provide to you or a family member. They may not seek more than their
governing laws allow. You may be responsible to pay for certain services and charges.
Contact the government facility directly for more information.
When Government
facilities bill us
20 2015 Coventry Health Care of Louisiana, Inc. Section 4
High and Standard Option Benefits Table of Contents
High and Standard Option
See page 9 for how our benefits changed this year, pages 70-71 for a benefit summary. Make sure that you review the
benefits that are available under the option in which you are enrolled.
Section 5. High and Standard Option Benefits Overview ..........................................................................................................23
Section 5(a). Medical services and supplies provided by physicians and other health care professionals .................................24
Diagnostic and treatment services .....................................................................................................................................24
Lab, X-ray and other diagnostic tests ................................................................................................................................24
Preventive care, adult ........................................................................................................................................................25
Preventive care, children ...................................................................................................................................................26
Maternity care ...................................................................................................................................................................26
Family planning ................................................................................................................................................................27
Infertility services .............................................................................................................................................................27
Allergy care .......................................................................................................................................................................28
Treatment therapies ...........................................................................................................................................................28
Physical and occupational therapies .................................................................................................................................28
Speech therapy ..................................................................................................................................................................29
Hearing services (testing, treatment, and supplies) ...........................................................................................................29
Vision services (testing, treatment, and supplies) .............................................................................................................30
Foot care ............................................................................................................................................................................30
Orthopedic and prosthetic devices ....................................................................................................................................30
Durable medical equipment (DME) ..................................................................................................................................31
Home health services ........................................................................................................................................................31
Chiropractic .......................................................................................................................................................................32
Alternative treatments .......................................................................................................................................................32
Section 5(b). Surgical and anesthesia services provided by physicians and other health care professionals .............................33
Surgical procedures ...........................................................................................................................................................33
Reconstructive surgery ......................................................................................................................................................35
Oral and maxillofacial surgery ..........................................................................................................................................35
Organ/tissue transplants ....................................................................................................................................................36
Anesthesia .........................................................................................................................................................................42
Section 5(c). Services provided by a hospital or other facility, and ambulance services ...........................................................43
Inpatient hospital ...............................................................................................................................................................43
Outpatient hospital or ambulatory surgical center ............................................................................................................44
Extended care benefits/Skilled nursing care facility benefits ...........................................................................................44
Hospice care ......................................................................................................................................................................45
Ambulance ........................................................................................................................................................................45
Section 5(d). Emergency services/accidents ...............................................................................................................................46
Emergency within our service area ...................................................................................................................................47
Emergency outside our service area ..................................................................................................................................47
Ambulance ........................................................................................................................................................................48
Section 5(e). Mental health and substance abuse benefits ..........................................................................................................49
Professional Services ........................................................................................................................................................49
Diagnostics ........................................................................................................................................................................50
Inpatient hospital or other covered facility .......................................................................................................................50
Outpatient hospital or other covered facility .....................................................................................................................50
Not covered .......................................................................................................................................................................50
Section 5(f). Prescription drug benefits ......................................................................................................................................51
21 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5
High and Standard Option
Covered medications and supplies ....................................................................................................................................52
Section 5(g). Dental benefits .......................................................................................................................................................53
Accidental injury benefit ...................................................................................................................................................53
Dental benefits ..................................................................................................................................................................53
Section 5(h). Special features ......................................................................................................................................................54
24 hour nurse line ..............................................................................................................................................................54
Coventry Wellbeing Program ............................................................................................................................................54
Flexible benefits option .....................................................................................................................................................54
My Online Services ...........................................................................................................................................................54
Section 5(i). Health education resources and tools .....................................................................................................................55
Summary of benefits for the High Option of Coventry Health Care of Louisiana 2015 ............................................................74
Summary of benefits for the Standard Option of Coventry Health Care of Louisiana 2015 ......................................................75
22 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5
Section 5. High and Standard Option Benefits Overview
High and Standard Option
This Plan offers both a High and Standard Option. Both benefit packages are described in Section 5. Make sure that you
review the benefits that are available under the option in which you are enrolled.
The High and Standard Option Section 5 is divided into subsections. Please read
Important things you should keep in mind
at
the beginning of the subsections. Also read the general exclusions in Section 6; they apply to the benefits in the following
subsections. To obtain claim forms, claims filing advice, or more information about High and Standard Option benefits,
contat us at 800-341-6613 or on our Website www.chcla.com.
Each option offers unique features.
•You are not required to select a primary care physician. Please be sure the provider you select - or the provider or the
facility you are referred to - is part of the Coventry Health Care of Louisiana HMO Network. It is ultimately your
responsibility to verify this information. By doing so, you get the most from your health Plan and protect yourself from
paying more than you have to for covered benefits.
•You do not need a referral from a participating Coventry Health Care of Louisiana primary care physician to see a
participating Coventry Health Care of Louisiana specialist.
23 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option
Section 5(a). Medical services and supplies
provided by physicians and other health care professionals
High and Standard Option
Important things you should keep in mind about these benefits:
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.
•Plan physicians must provide or arrange your care.
•A facility copay applies to services that appear in this section but are performed in an ambulatory
surgical center or the outpatient department of a hospital.
•High Option – The calendar year deductible is $500 per person and $1,000 per family. 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.
•Standard Option - The calendar year deductible is $1,000 per person and $2,000 per family. 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.
•Be sure to read Section 4,
Your costs for covered services
, for valuable information about how cost-
sharing works. Also read Section 9 about coordinating benefits with other coverage, including with
Medicare.
Benefit Description You Pay
Diagnostic and treatment services High Option Standard Option
Professional services of physicians
• In physician’s office
No deductible
$25 per visit to a primary care
physican
$45 per visit to a specialist
No deductible
$30 per visit to a primary care
physician
$55 per visit to a specialist
Professional services of physicians No deductible No deductible
• In an Urgent Care Center $75 per visit $75 per visit
• Office Medical Consultation
• Second Surgical Opinion
$45 per visit to a specialist $55 per visit to a specialist
• At home No deductible
$25 per visit
No deductible
$25 per visit
Lab, X-ray and other diagnostic tests High Option Standard Option
Tests, such as:
• Blood tests
• Urinalysis
• Non-routine Pap tests
• Pathology
• X-rays
• Non-routine mammograms
• Ultrasound
• Electrocardiogram and EEG
Nothing if you receive these
services during your office
visit, otherwise $25 per visit to
a primary care physician; $45
per visit to a specialist, No
deductible
Nothing if you receive these
services during your office
visit, otherwise $30 per visit to
a primary care physician; $55
per visit to a specialist, No
deductible
• CAT Scans/MRI $50 copayment after the
deductible
Deductible applies, then 30%
coinsurance
24 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5(a)
High and Standard Option
Benefit Description You Pay
Preventive care, adult High Option Standard Option
Routine screenings, such as:
• Total Blood Cholesterol
• Colorectal Cancer Screening, including
- Colonoscopy screening – every ten years starting
at age 50
- routine mammogram - covered for women age
35 and older, as follows:
- From age 35 through 39, one during this five
year period
- From age 40 throught 64, one every calendar
year
- At age 65 and older, one every two consecutive
calendar years
Nothing, No Deductible
Applies
Nothing, No Deductible
Applies
Routine Prostate Specific Antigen (PSA) test – one
annually for men age 40 and older
Nothing, No Deductible
Applies
Nothing, No Deductible
Applies
Well woman care including, but not limited to:
•Routine Pap test
•Human papillomavirus testing for women age 30 and
up once every three years
•Annual counseling for sexually transmitted
infections.
•Annual counseling and screening for human
immune-deficiency virus.
•Contraceptive methods and counseling.
•Screening and counseling for interpersonal and
domestic violence.
Nothing, No Deductible
Applies
Nothing, No Deductible
Applies
Routine mammogram covered for women age 35 and
older, as follows:
• From age 35 through 39, one during this five year
period
• From age 40 through 64, one every claendar year
• At age 65 and older, one every two consecutive
calendar years
Nothing, No Deductible
Applies
Nothing, No Deductible
Applies
Adult routine immunizations endorsed by the Centers
for Disease Control and Prevention (CDC):
Nothing, No Deductible
Applies
Nothing, No Deductible
Applies
Note: A complete list of preventive care services
recommended under the U.S. Preventitve Services
Task Force (USPSTF) is available online at http://
www.uspreventiveservicestaskforce.org/uspstf/
uspsabrecs.htm.
Not covered: Physical exams and immunizations
required for obtaining or continuing employment or
insurance, attending schools or camp, or travel.
All charges All charges
25 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5(a)
High and Standard Option
Benefit Description You Pay
Preventive care, children High Option Standard Option
• Childhood immunizations recommended by the
American Academy of Pediatrics
Nothing, No Deductible
Applies
Nothing, No Deductible
Applies
• Well-child care charges for routine examinations,
immunizations and care (up to age 22)
• Examinations, such as:
- Eye exams through age 17 to determine the need
for vision correction
- Ear exams through age 17 to determine the need
for hearing correction
- Examinations done on the day of immunizations
(up to age 22)
Nothing, No Deductible
Applies
Nothing, No Deductible
Applies
Note: A complete list of preventive care services
recommended under the U.S. Preventive Services
Task Force (USPSTF) is available online at http://
www.uspreventiveservicetaskforce.org/uspstf/
uspsabrecs.htm.
Maternity care High Option Standard Option
Screening for gestational diabetes for pregnant
women between 24-28 weeks gestation or first
prenatal visit for women at a high risk.
Nothing Nothing
Complete maternity (obstetrical) care, such as:
• Prenatal care
• Delivery
• Postnatal care
Note: Here are some things to keep in mind:
• You do not need to precertify your normal delivery;
see below for other circumstances, such as
extended stays for you or your baby.
• You may remain in the hospital up to 48 hours after
a regular delivery and 96 hours after a cesarean
delivery. We will extend your inpatient stay if
medically necessary.
• We cover routine nursery care of the newborn child
during the covered portion of the mother’s
maternity stay. We will cover other care of an
infant who requires non-routine treatment only if
we cover the infant under a Self and Family
enrollment.
• We pay hospitalization and surgeon services the
same as for illness and injury.
No deductible
$45 per office visit for initial
visit only
No deductible
$55 copayment for initial visit
only
Breastfeeding support, supplies and counseling for
each birth
Nothing Nothing
26 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5(a)
High and Standard Option
Benefit Description You Pay
Family planning High Option Standard Option
A range of voluntary family planning services,
limited to:
• Surgically implanted contraceptives
• Injectable contraceptive drugs (such as Depo
provera)
• Diaphragms
Note: We cover oral contraceptives under the
prescription drug benefit.
Nothing Nothing
• Voluntary sterilization (vasectomy or tubal
ligation)
Nothing for female members.
For male members, all of our
allowable amounts up to the
deductible amount and nothing
thereafter
Nothing for female members.
For male members, deductible
applies, then 30% coinsurance
Not covered:
•
Reversal of voluntary surgical sterilization
•
Genetic counseling
•
Intrauterine Devices (IUDs)
All charges All charges
Contraceptive counseling on an annual basis Nothing Nothing
Infertility services High Option Standard Option
Diagnosis and treatment of infertility such as:
• Artificial insemination:
- Intravaginal insemination (IVI)
- Intracervical insemination (ICI)
- Intrauterine insemination (IUI)
Deductible applies, then 50%
coinsurance
Deductible applies, then 30%
coinsurance
Not covered:
•
Assisted reproductive technology (ART)
procedures, such as:
-
in vitro fertilization
-
embryo transfer, gamete intra-fallopian transfer
(GIFT) and zygote intra-fallopian transfer
(ZIFT)
•
Services and supplies related to ART procedures
•
Cost of donor sperm
•
Cost of donor egg.
•
Fertility Drugs
All charges All charges
27 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5(a)
High and Standard Option
Benefit Description You Pay
Allergy care High Option Standard Option
• Testing and treatment All of our allowable amounts
up to the deductible amount
and nothing thereafter
Deductible applies, then 30%
coinsurance
• Allergy injections No deductible
$25 per visit to primary care
physician
$45 per visit to specialist office
visit
No deductible
$30 per visit to a primary care
physician
$55 per visit to a specialist
Allergy Serum Nothing Nothing
Not covered:
•
Provocative food testing
•
Sublingual allergy desensitization
All charges All charges
Treatment therapies High Option Standard Option
• Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with
autologous bone marrow transplants is limited to
those transplants listed under Organ/Tissue
Transplants on page 30.
• Respiratory and inhalation therapy
• Dialysis – hemodialysis and peritoneal dialysis
• Intravenous (IV)/Infusion Therapy – Home IV and
antibiotic therapy
• Growth hormone therapy (GHT)
Note: We only cover GHT when we preauthorize the
treatment. We will ask you to submit information that
establishes that the GHT is medically necessary. Ask
us to authorize GHT before you begin treatment. We
will only cover GHT services and related services and
supplies that we determine medically necessary. See
Other services under You need prior Plan approval for
certain services on page 15.
All of our allowable amounts
up to the deductible amount
and nothing thereafter
Deductible applies, then 30%
coinsurance
Physical and occupational therapies High Option Standard Option
60 visits per condition for the services of each of the
following:
• qualified physical therapists
• occupational therapists
Note: We only cover therapy when a provider orders
the care.
All of our allowable amounts
up to the deductible amount
and nothing thereafter
Deductible applies, then 30%
coinsurance
Cardiac Rehabilitation following a heart transplant,
bypass surgery or a myocardial infarction is provided
for up to 36 visits.
All of our allowable amounts
up to the deductible amount
and nothing thereafter.
Deductible applies, then 30%
coinsurance
Not covered: All charges All charges
Physical and occupational therapies - continued on next page
28 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5(a)
High and Standard Option
Benefit Description You Pay
Physical and occupational therapies (cont.) High Option Standard Option
•
Long-term rehabilitative therapy
•
Exercise programs
All charges All charges
Speech therapy High Option Standard Option
60 visits per condition All of our allowable amounts
up to the deductible amount
and nothing thereafter
Deductible applies, then 30%
coinsurance
Habilitative therapy High Option Standard Option
60 visits per condition $25 per visit to a primary care
physician
$45 per visit to a specialist
$30 per visit to a primary care
physician
$55 per visit to a specialist
Applied Behavorial Analysis (ABA)
Therapy for Autism Spectrum Disorder
High Option Standard Option
Therapy services provided for ABA in a providers
office.
$45 specialist office visit $55 specialist office visit
Hearing services (testing, treatment, and
supplies)
High Option Standard Option
Hearing aids - we limit coverage to$1,400 per device
per calendar year.
Nothing Nothing
• For treatment related to illness or injury, including
evaluation and diagnostic hearing tests performed
by an M.D., D.O., or audiologist
Note: For routine hearing screening performed during
a child’s preventive care visit, see Section 5(a)
Preventive care, children.
• Implanted hearing-related devices, such as bone
anchored hearing aids (BAHA) and cochlear
implants
Note: For benefits for the devices, see Section 5(a)
Orthopedic and prosthetic devices
.
No deductible
$25 per visit to a primary care
physician
$45 per visit to a specialist
No deductible
$30 per visit to a primary care
physician
$55 per visit to a specialist
Not covered:
•
Hearing aid batteries
•
Replacement hearing aid devices within the same
calendar year
•
Hearing devices and services that are not
specifically listed in the covered services section
All charges All charges
29 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5(a)
High and Standard Option
Benefit Description You Pay
Vision services (testing, treatment, and
supplies)
High Option Standard Option
• Diagnosis and treatment of diseases of the eye No deductible
$45 per office visit
No deductible
$55 per office visit
• Prosthetic devices, such as lenses following
cataract removal
No deductible
$45 per office visit
No deductible
$55 per office visit
Not covered:
•
Eyeglasses
or contact lenses and after age 17,
examinations for them
•
Eye exercises and orthoptics
•
Radial keratotomy and other refractive surgery
•
Annual eye refractions
All charges All charges
Foot care High Option Standard Option
Routine foot care when you are under active
treatment for a metabolic or peripheral vascular
disease, such as diabetes.
Note: See Orthopedic and prosthetic devices for
information on podiatric shoe inserts.
No deductible
$25 per visit to a primary care
physician
$45 per visit to a specialist
No deductible
$30 per visit to a primary care
physician
$55 per visit to a specialist
Not covered:
•
Cutting, trimming or removal of corns, calluses, or
the free edge of toenails, and similar routine
treatment of conditions of the foot, except as stated
above
•
Treatment of weak, strained or flat feet or bunions
or spurs; and of any instability, imbalance or
subluxation of the foot (unless the treatment is by
open cutting surgery)
All charges All charges
Orthopedic and prosthetic devices High Option Standard Option
• Artificial limbs and eyes
• Stump hose
• Externally worn breast prostheses and surgical
bras, including necessary replacements following a
mastectomy
• Corrective orthopedic appliances for non-dental
treatment of temporomandibular joint (TMJ) pain
dysfunction syndrome.
• Hearing aids-we limit coverage to $1,400 per
device per calendar year
• Implanted hearing-related devices, such as bone
anchored hearing aids (BAHA) and cochlear
implants
• Internal prosthetic devices, such as artificial joints,
pacemakers, and surgically implanted breast
implant following mastectomy.
All of our allowable amounts
up to the deductible amount
and nothing thereafter
Deductible applies, then 30%
coinsurance
Orthopedic and prosthetic devices - continued on next page
30 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5(a)
High and Standard Option
Benefit Description You Pay
Orthopedic and prosthetic devices (cont.) High Option Standard Option
Note: For information on the professional charges for
the surgery to insert an implant, see Section 5(b)
Surgical procedures. For information on the hospital
and/or ambulatory surgery center benefits, see
Section 5(c) Services provided by a hospital or other
facility, and ambulance services.
All of our allowable amounts
up to the deductible amount
and nothing thereafter
Deductible applies, then 30%
coinsurance
Not covered:
•
Orthopedic and corrective shoes , a rch supports ,
f oot orthotics , h eel pads and heel cups
•
Lumbosacral supports
•
Corsets, trusses, elastic stockings, suppor t hose,
and other supportive devices
All charges All charges
Durable medical equipment (DME) High Option Standard Option
Rental or purchase, at our option, including repair and
adjustment, of durable medical equipment prescribed
by your Plan physician, such as oxygen and dialysis
equipment. Under this benefit, we also cover:
• Oxygen
• Dialysis equipment
• Hospital beds
• Wheelchairs
• Crutches
• Walkers
• Blood glucose monitors
• Insulin pumps
Note: Call us at 800-341-6613 as soon as your Plan
physician prescribes this equipment.
All of our allowable amounts
up to the deductible amount
and nothing thereafter
Deductible applies, then 30%
coinsurance
Not covered: Convenience items All charges All charges
Home health services High Option Standard Option
• Home health care ordered by a Plan physician and
provided by a registered nurse (R.N.), licensed
practical nurse (L.P.N.), licensed vocational nurse
(L.V.N.), or home health aide.
• Services include oxygen therapy, intravenous
therapy and medications.
All of our allowable amounts
up to the deductible amount
and nothing thereafter
Deductible applies, then 30%
coinsurance
Not covered:
•
Nursing care requested by, or for the convenience
of, the patient or the patient’s family;
•
Home care primarily for personal assistance that
does not include a medical component and is not
diagnostic, therapeutic, or rehabilitative.
•
Nursing aides
All charges All charges
31 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5(a)
High and Standard Option
Benefit Description You Pay
Chiropractic High Option Standard Option
• Manipulation of the spine and extremities
After initial evaluation, treatment plan must be
submitted to Coventry Health Care to authorize
additional visits.
No deductible
$25 per office visit
No deductible
$30 per office visit
Alternative treatments High Option Standard Option
No benefit
All charges All charges
Educational classes and programs High Option Standard Option
Coverage is provided for:
• Tobacco cessation programs, including individual/
group/telephone counseling, and for over the
counter (OTC) and prescription drugs approved by
the FDA to treat tobacco dependence.
• Childhood obesity education
Nothing up to four counseling
sessions for up to two quit
attempts per year.
Nothing for OTC and
prescription drugs approved by
the FDA to treat tobacco
dependence.
Nothing (for details refer to
our website at chcla@cvty.com)
Nothing up to four counseling
sessions for up to two quit
attempts per year.
Nothing for OTC and
prescription drugs approved by
the FDA to treat tobacco
dependence.
Nothing (for details refer to our
website at chcla@cvty.com)
32 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5(a)
Section 5(b). Surgical and anesthesia services provided by physicians and other
health care professionals
High and Standard Option
Important things you should keep in mind about these benefits:
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.
•Plan physicians must provide or arrange your care.
•High Option – The calendar year deductible is $500 per person and $1,000 per family.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.
•Standard Option - The calendar year deductible is $1,000 per person and $2,000 per family.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.
•Be sure to read Section 4, Your costs for covered services, for valuable information about how cost-
sharing works. Also read Section 9 about coordinating benefits with other coverage, including with
Medicare.
•The services listed below are for the charges billed by a physician or other health care professional
for your surgical care. See Section 5(c) for charges associated with the facility (i.e. hospital, surgical
center, etc.).
•YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME SURGICAL
PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure
which services require precertification and identify which surgeries require precertification.
Benefit Description You pay
Surgical procedures High Option Standard Option
A comprehensive range of services, such as:
• Operative procedures
• Treatment of fractures, including casting
• Normal pre- and post-operative care by the surgeon
• Endoscopy procedures
• Biopsy procedures
• Removal of tumors and cysts
• Correction of congenital anomalies (see
Reconstructive surgery)
All of our allowable amounts
up to the deductible amount
and nothing thereafter
Deductible applies, then 30%
coinsurance
• Surgical treatment of morbid obesity(biatric
surgery) will be covered when all of the following
criteria are met:
- The patient is an adult (> 18 years of age) with
morbid obesity that has persisted for at least 3
years, and for which there is no treatable
metabolic cause for the obesity;
All of our allowable amounts
up to the deductible amount
and nothing thereafter
Deductible applies, then 30%
coinsurance
Surgical procedures - continued on next page
33 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5(b)
High and Standard Option
Benefit Description You pay
Surgical procedures (cont.) High Option Standard Option
- There is presence of morbid obesity, defined as a
body mass index (BMI) exceeding 40, or greater
than 35 with documented co-morbid conditions
(cardiopulmonary problems e.g., severe apnea,
Pickwickian Syndrome, and obesity-related
cardiomyopathy, severe diabetes mellitus,
hypertension, or arthritis). (BMI is calculated by
dividing a patient’s weight (in kilograms) by
height (in meters) squared. To convert pounds to
kilograms, multiply pounds by 0.45. To convert
inches to meters, multiply inches by .0254);
- The patient has failed to lose weight
(approximately 10% from baseline) or has
regained weight despite participation in a three
month physician-supervised multidisciplinary
program within the past six months that included
dietary therapy, physical activity and behavior
therapy and support;
- The patient has been evaluated for restrictive
lung disease and received surgical clearance by a
pulmonologist, if clinically indicated; has
received cardiac clearance by a cardiologist if
there is a history of prior phen-fen or redux use,
and the patient has agreed, following surgery, to
participate in a multidisciplinary program that
will provide guidance on diet, physical activity
and social support; and,
- The patient has completed a psychological
evaluation and has been recommended for
bariatric surgery by a licensed mental health
professional (this must be documented in the
patient’s medical record) and the patient’s
medical record reflects documentation by the
treating psychotherapist that all psychosocial
issues have been identified and addressed; and
the psychotherapist indicates that the patient is
likely to be compliant with the post-operative
diet restrictions;
• Insertion of internal prosthetic devices. See 5(a) –
Orthopedic and prosthetic devices for device
coverage information
• Treatment of burns
All of our allowable amounts
up to the deductible amount
and nothing thereafter
Deductible applies, then 30%
coinsurance
• Voluntary Sterilization (e.g., Tubal ligation,
Vasectomy)
All of our allowable amounts
up to the deductible amount
and nothing thereafter
Deductible applies, then 30%
coinsurance
Not covered:
•
Reversal of voluntary sterilization
•
Routine treatment of conditions of the foot; see
Foot care
All charges All charges
34 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5(b)
High and Standard Option
Benefit Description You pay
Reconstructive surgery High Option Standard Option
• Surgery to correct a functional defect
• Surgery to correct a condition caused by injury or
illness if:
- the condition produced a major effect on the
member’s appearance and
- can reasonably be expected to be corrected by
such surgery
• Surgery to correct a condition that existed at or
from birth and is a significant deviation from the
common form or norm. Examples of congenital
anomalies are: protruding ear deformities; cleft lip;
cleft palate; birth marks; webbed fingers; and
webbed toes.
• All stages of breast reconstruction surgery
following a mastectomy, such as:
- surgery to produce a symmetrical appearance of
breasts;
- treatment of any physical complications, such as
lymphedemas;
- breast prostheses and surgical bras and
replacements (see Prosthetic devices)
Note: If you need a mastectomy, you may choose to
have the procedure performed on an inpatient basis
and remain in the hospital up to 48 hours after the
procedure.
All of our allowable amounts
up to the deductible amount
and nothing thereafter
Deductible applies, then 30%
coinsurance
Not covered:
•
Cosmetic surgery – any surgical procedure (or any
portion of a procedure) performed primarily to
improve physical appearance through change in
bodily form, except repair of accidental injury
•
Surgeries related to sex transformation
All charges All charges
Oral and maxillofacial surgery High Option Standard Option
Oral surgical procedures, limited to:
• Reduction of fractures of the jaws or facial bones;
• Surgical correction of cleft lip, cleft palate or
severe functional malocclusion;
• Removal of stones from salivary ducts;
• Excision of leukoplakia or malignancies;
• Excision of cysts and incision of abscesses when
done as independent procedures; and
• Other surgical procedures that do not involve the
teeth or their supporting structures.
All of our allowable amounts
up to the deductible amount
and nothing thereafter
Deductible applies, then 30%
coinsurance
Not covered:
•
Oral implants and transplants
All charges All charges
Oral and maxillofacial surgery - continued on next page
35 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5(b)
High and Standard Option
Benefit Description You pay
Oral and maxillofacial surgery (cont.) High Option Standard Option
•
Procedures that involve the teeth or their
supporting structures (such as the periodontal
membrane, gingiva, and alveolar bone)
•
Dental care involved in treatment of
temporomandibular joint (TMJ) pain dysfunction
syndrome
All charges All charges
Organ/tissue transplants High Option Standard Option
These solid organ transplants are subject to
medical necessity and experimental /investigational
review by the Plan. Refer to Other Services in Section
3 for prior authorization procedures. Transplant
services must be performed at a participating Center
of Excellence. We approve and designate where all
transplants must be performed including hospitals for
specific transplant procedures. If you would like to
know about a specific facility, please contact
Customer Service.
We cover related medical and hospital expenses of
donor when the expenses are not covered by the
donor's insurance and when the transplant recipient is
a Coventry member approved for transplant services.
Solid organ transplants limited to:
• Cornea
• Heart
• Heart/lung
• Kidney
• Liver
• Pancreas*
• Kidney/Pancreas
• Lung: single/bilateral/Lobar
• Intestinal transplants
- isolated small intestine
- small intestine with the liver
- small intestine with multiple organs such as
the liver, stomach, and pancreas
• Autologous pancreas islet cell transplant (as an
adjunct to total or near total pancreatectomy) only
for patients with chronic pancreatitis.
* We limit the coverage for pancreas (only)
transplants to patients who have insulin dependent (or
Type 1) diabetes mellitus when we find that
exogenous treatment with insulin is ineffective.
All of our allowable amounts
up to the deductible amount
and nothing thereafter
Deductible applies, then 30%
coinsurance
Organ/tissue transplants - continued on next page
36 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5(b)
High and Standard Option
Benefit Description You pay
Organ/tissue transplants (cont.) High Option Standard Option
These tandem blood or marrow stem cell
transplants for covered transplants are subject to
medical necessity review by the Plan. Refer to
Other
services
in Section 3 for prior authorization
procedures.
• Autologous tandem transplants for
- AL Amyloidosis
- Multiple myeloma (de novo and treated)
- Recurrent germ cell tumors (including testicular
cancer)
All of our allowable amounts
up to the deductible amount
and nothing thereafter
Deductible applies, then 30%
coinsurance
Blood or marrow stem cell transplants limited to
the stages of the following diagnoses. For the
diagnoses listed below, the medical necessity
limitation is considered satisfied if the patient meets
the staging description.
Physicians consider many features to determine how
diseases will respond to different types of treatment.
Some of the features measured are the presence or
absence of normal and abnormal chromosomes, the
extension of the disease throughout the body, and
how fast the tumor cells grow. By analyzing these
and other characteristics, physicians can determine
which diseases may respond to treatment without
transplant and which diseases may respond to
transplant.
Allogeneic (donor) transplants for:
• Acute lymphocytic or non-lymphocytic leukemia
• Advanced Hodgkin’s lymphoma with recurrence
(relapsed)
• Advanced non-Hodgkin’s lymphoma with
recurrence (relapsed)
• Acute myeloid leukemia
• Advanced Myeloproliferative Disorder (MPDs)
• Advanced Neuroblastoma
• Amyloidosis
• Chronic lymphocytic lymphoma /small
lymphocytic lymphoma (CLL/SLL)
• Hemoglobinopathy
• Infant malignant osteopetrosis
• Kostmann’s syndrome
• Leukocyte adhesion deficiencies
• Marrow Failure and Related Disorders (i.e.
Fanconi's, PNH, pure red cell aplasia)
All of our allowable amounts
up to the deductible amount
and nothing thereafter
Deductible applies, then 30%
coinsurance
Organ/tissue transplants - continued on next page
37 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5(b)
High and Standard Option
Benefit Description You pay
Organ/tissue transplants (cont.) High Option Standard Option
• Mucolipidosis (e.g. Gaucher’s disease,
metachromatic leukodystrophy,
adrenoleukodystrophy)
• Mucopolysaccharidosis (e.g. Hunter’s Syndrome,
Hurler’s syndrome, Sanfillippo’s syndrome,
Maroteauxlamy syndrome variants)
• Myelodysplasia/Myelodysplastic syndromes
• Paroxysmal Nocturnal Hemoglobinuria
• Phagocytic / Hemophagocytic deficiency diseases
(e.g. Wiskott-Aldrich syndrome)
• Severe combined immune-deficiency disease
• Severe or very severe aplastic anemia
• Sickle cell anemia
Autologous Transplants for:
• Acute lymphocytic or non-lymphocytic (i.e.,
myelogenous) leukemia
• Advanced Childhood kidney cancers
• Advanced Ewing sarcoma Breast Cancer
• Advanced Hodgkin’s lymphoma with recurrence
(relapsed)
• Advanced non-Hodgkin’s lymphoma with
recurrence (relapsed)
• Aggressive non-Hodgkin Lymphomas
• Amyloidosis
• Advanced Neuroblastoma
• Childhood rhabdomyosarcoma
• Epithelial Ovarian Cancer
• Mantle Cell (Non-Hodgkin lymphoma)
• Multiple Myeloma
• Testicular, Mediastinal, Retroperitoneal, and
ovarian germ cell tumors
All of our allowable amounts
up to the deductible amount
and nothing thereafter
Deductible applies, then 30%
coinsurance
Mini Transplants performed in a clinical trial
setting (non-myeloblative, reduced intensity
conditioning or RIC) for members with a diagnosis
listed below are subject to medical necessity review
by the Plan.
Refer to Other Services in Section 3 for prior
authorization procedures:
Allogeneic transplants for:
• Acute lymphocytic or non-lymphocytic leukemia
• Advanced Hodgkin’s lymphoma with recurrence
(relapsed)
All of our allowable amounts
up to the deductible amount
and nothing thereafter
Deductible applies, then 30%
thereafter
Organ/tissue transplants - continued on next page
38 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5(b)
High and Standard Option
Benefit Description You pay
Organ/tissue transplants (cont.) High Option Standard Option
• Advanced non-Hodgkin’s lymphoma with
recurrence (relapsed)
• Acute myeloid leukemia
• Advanced Myeloproliferative Disorder (MPDs)
• Amyloidosis
• Chronic lymphocytic lymphoma /small
lymphocytic lymphoma (CLL/SLL)
• Hemoglobinopathy
• Marrow Failure and Related Disorders (i.e.
Fanconi's, PNH, pure red cell aplasia)
• Myelodysplasia/Myelodysplastic syndromes
• Paroxysmal Nocturnal Hemoglobinuria
• Severe combined immuno-deficiency disease
• Severe or very severe aplastic anemia
Autologous transplants for:
• Acute lymphocytic or non-lymphocytic leukemia
• Advanced Hodgkin’s lymphoma with recurrence
(relapsed)
• Advanced non-Hodgkin’s lymphoma with
recurrence (relapsed
• Amyloidosis
• Neuroblastoma
• Breast cancer
• Epithelial ovarian cancer
All of our allowable amounts
up to the deductible amount
and nothing thereafter
Deductible applies, then 30%
thereafter
These blood or marrow stem cell transplants are
covered only in a National Cancer Institute or
National Institutes of health approved clinical trial
or a Plan-designated center of excellence and if
approved by the Plan’s medical director in
accordance with the Plan’s protocols.
If you are a participant in a clinical trial, the Plan will
provide benefits for related routine care that is
medically necessary (such as doctor visits, lab tests,
x-rays and scans, and hospitalization related to
treating the patient’s condition) if it is not provided
by the clinical trial. Section 9 has additional
information on costs related to clinical trials. We
encourage you to contact the Plan to discuss specific
services if you participate in a clinical trial.
These blood and marrow stem cell transplants are
covered if the following are met:
• The trial is a NCI and/ or NIH sponsored trial; or
• The trial is conducted at an approved NCI center;
and
All of our allowable amounts
up to the deductible amount
and nothing thereafter
Deductible applies, then 30%
coinsurance
Organ/tissue transplants - continued on next page
39 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5(b)
High and Standard Option
Benefit Description You pay
Organ/tissue transplants (cont.) High Option Standard Option
• The trial is approved by the Plan’s Medical
Director in accordance with the Plan’s protocols.
Allogeneic transplants for:
• Advanced Hodgkin’s lymphoma
• Advanced non-Hodgkin’s lymphoma
• Early stage (indolent or non-advanced) small cell
lymphocytic lymphoma
Mini-transplants (non-myeloblative allogeneic,
reduced intensity conditioning or RIC) for
• Acute lymphocytic or non-lymphocytic leukemia
• Advanced Hodgkin’s lymphoma
• Advanced non-Hodgkin’s lymphoma
• Breast Cancer
• Chronic lymphocytic leukemia
• Chronic myelogenous leukemia
• Colon cancer
• Chronic lymphocytic lymphoma /small
lymphocytic lymphoma (CLL/SLL)
• Early stage (indolent or non-advanced) small cell
lymphocytic lymphoma
• Multiple Myeloma
• Multiple sclerosis
• Myeloproliferative Disorder (MPDs)
• Non-small lung cancer
• Ovarian cancer
• Prostate cancer
• Renal cell carcinoma
• Sarcomas
• Sickle cell anemia (pediatric only)
• Autologous Transplants for
• Advanced Childhood kidney cancers
• Advanced Ewing sarcoma
• Advanced Hodgkin’s lymphoma
• Advanced non-Hodgkin’s lymphoma
• Breast Cancer
• Childhood rhabdomyosarcoma
• Chronic myelogenous leukemia
• Chronic lymphocytic lymphoma /small
lymphocytic lymphoma (CLL/SLL)
• Early stage (indolent or non-advanced) small cell
lymphocytic lymphoma
All of our allowable amounts
up to the deductible amount
and nothing thereafter
Deductible applies, then 30%
coinsurance
Organ/tissue transplants - continued on next page
40 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5(b)
High and Standard Option
Benefit Description You pay
Organ/tissue transplants (cont.) High Option Standard Option
• Epithelial Ovarian Caner
• Mantle Cell (Non-Hodgkin lymphoma)
• Multiple sclerosis
• Small cell lung cancer
• Systemic lupus erythematosus
• Systemic sclerosis
All of our allowable amounts
up to the deductible amount
and nothing thereafter
Deductible applies, then 30%
coinsurance
Coventry Transplant Network (CTN) -
NOTE: We cover related medical and hospital
expenses of the donor when we cover the recipient.
We cover donor testing for the actual solid organ or
up to four bone marrow /stem cell transplant donors
in addition to the testing of family members.
After referral to a transplant facility, the following
will apply:
• If our Medical Director or the referral facility
decides you do not satisfy criteria for a transplant,
we only pay for covered services you receive
before that decision is made
• We, and the Plan providers are not responsible for
finding, furnishing, or ensuring the availability of a
bone marrow or organ donor
• We cover reasonable medical and hospital
expenses as long as the expenses are directly
related to a covered transplant of the donor or an
individual identified as a potential donor.
• Unless otherwise authorized by our Medical
Director, we provide transplants only at approved
Transplant Network facilities
Not Covered:
•
Donor screening tests and donor search expenses,
except as shown above.
•
Any related conditions or complications for a
member who is donating an organ or tissue when
the recipient is not a member
•
Outpatient immunosuppressive agents
•
Any transplant procedure that is performed in a
facility that has not been designated by the Medical
Director as a approved transplant facility
•
Implants of non-human or artificial organs
•
Transplants not listed as covered
All charges All charges
41 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5(b)
High and Standard Option
Benefit Description You pay
Anesthesia High Option Standard Option
Professional services provided in –
• Hospital
• Skilled nursing facility
• Ambulatory surgical center
All of our allowable amounts
up to the deductible amount
and nothing thereafter
Deductible applies, then 30%
coinsurance
Office No deductible
$25 per visit to a primary care
physician
$45 per visit to a specialist
No deductible
$30 per visit to a primary care
physician
$55 per visit to a specialist
42 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5(b)
Section 5(c). Services provided by a hospital or
other facility, and ambulance services
High and Standard Option
Important things you should keep in mind about these benefits:
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.
•Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.
•High Option – The calendar year deductible is $500 per person and $1,000 per family. The calendar
year deductible applies to almost all benefits in this section. We added "(No deductible)" when it
does not applies.
•Standard Option - The calendar year deductible is $1,000 per person and $2,000 per family. The
calendar year deductible applies to almost all benefits in this section. We added "(No deductible)"
when it does not applies.
•Be sure to read Section 4,
Your costs for covered services
for valuable information about how cost-
sharing works. Also read Section 9 about coordinating benefits with other coverage, including with
Medicare.
•The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center)
or ambulance service for your surgery or care. Any costs associated with the professional charge (i.
e., physicians, etc.) are in Sections 5(a) or (b).
•YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR HOSPITAL STAYS. Please
refer to Section 3 to be sure which services require precertification.
Benefit Description You pay
Inpatient hospital High Option Standard Option
Room and board, such as
• Ward, semiprivate, or intensive care
accommodations;
• General nursing care
• Meals and special diets
Note: If you want a private room when it is not
medically necessary, you pay the additional charge
above the semiprivate room rate.
$100 copayment per hospital
admission after the calendar
year deductible.
Deductible applies, then 30%
coinsurance
Other hospital services and supplies, such as:
• Operating, recovery, maternity, and other treatment
rooms
• Prescribed drugs and medicines
• Diagnostic laboratory tests and X-rays
• Administration of blood, blood plasma, and other
biologicals
• Dressings, splints, casts, and sterile tray services
• Medical supplies and equipment, including oxygen
• Anesthetics, including nurse anesthetist services
• Take-home items
All of our allowable amounts
up to the deductible amount
and nothing thereafter
Deductible applies, then 30%
coinsurance
Inpatient hospital - continued on next page
43 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5(c)
High and Standard Option
Benefit Description You pay
Inpatient hospital (cont.) High Option Standard Option
• Medical supplies, appliances, medical equipment,
and any covered items billed by a hospital for use
at home (Note: calendar year deductible applies.)
All of our allowable amounts
up to the deductible amount
and nothing thereafter
Deductible applies, then 30%
coinsurance
Not covered:
•
Custodial care
•
Non-covered facilities, such as nursing homes,
schools
•
Personal comfort items, such as telephone,
television, barber services, guest meals and beds
•
Private nursing care
All charges All charges
Outpatient hospital or ambulatory surgical
center
High Option Standard Option
• Operating, recovery, and other treatment rooms
• Prescribed drugs and medicines
• Diagnostic laboratory tests, X-rays , and pathology
services
• Administration of blood, blood plasma, and other
biologicals
• Pre-surgical testing
• Dressings, casts , and sterile tray services
• Medical supplies, including oxygen
• Anesthetics and anesthesia service
Note: We cover hospital services and supplies related
to dental procedures when necessitated by a non-
dental physical impairment. We do not cover the
dental procedures.
$50 copayment facility charge
after the calendar year
deductible.
Deductible applies, then 30%
coinsurance
Not covered: Blood and blood derivatives not
replaced by the member
All charges All charges
Extended care benefits/Skilled nursing care
facility benefits
High Option Standard Option
High Option – We limit our coverage to 100 days per
calendar year
Standard Option - We limit our coverage to 30 days
per calendar year
Comprehensive range of benefits will be provided
when full-time skilled nursing care is necessary and
confinement in a skilled nursing facility is in lieu of
hospitalization.
Covered services include:
• Bed, board and general nursing care
All of our allowable amounts
up to the deductible amount
and nothing thereafter
Deductible applies, then 30%
coinsurance
Extended care benefits/Skilled nursing care facility benefits - continued on next page
44 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5(c)
High and Standard Option
Benefit Description You pay
Extended care benefits/Skilled nursing care
facility benefits (cont.)
High Option Standard Option
Drugs, biologicals, supplies, and equipment
ordinarily provided or arranged by the skilled nursing
facility when prescribed by a Plan doctor
All of our allowable amounts
up to the deductible amount
and nothing thereafter
Deductible applies, then 30%
coinsurance
Not covered: Custodial care All charges All charges
Hospice care High Option Standard Option
Supportive and palliative care for a terminally ill
member in the home or hospice facility. Services
include inpatient and outpatient care, and family
counseling. Services are provided under the direction
of a Plan doctor who certifies that the patient is in the
terminal stages of illness, with a life expectancy of
approximately six months or less.
All of our allowable amounts
up to the deductible amount
and nothing thereafter
Deductible applies, then 30%
coinsurance
Not covered: Independent nursing, homemaker
services
All charges All charges.
Ambulance High Option Standard Option
Local professional ambulance service when
medically appropriate
All of our allowable amounts
up to the deductible amount
and nothing thereafter
Deductible applies, then 30%
coinsurance
45 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5(c)
Section 5(d). Emergency services/accidents
High and Standard Option
Important things to keep in mind about these benefits:
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.
•Be sure to read Section 4,
Your costs for covered services,
for valuable information about how cost-
sharing works. Also read Section 9 about coordinating benefits with other coverage, including with
Medicare.
•High Option – The calendar year deductible is $500 per person and $1,000 per family. 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.
•Standard Option - The calendar year deductible is $1,000 per person and $2,000 per family. 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.
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or
could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies
because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are
emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or
sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies – what
they all have in common is the need for quick action.
What to do in case of emergency:
Emergencies within our service area: If you are in an emergency situation, contact the local emergency system (e.g., the
911 telephone system) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you
are a Plan member so they can notify the Plan.
If you need to be hospitalized in a non-Plan facility, the Plan must be notified within 24 hours or on the first working day
following your admission, unless it was not reasonably possible to notify the Plan within that time. If you are hospitalized in
non-Plan facilities and Plan doctors believe care can be better provided in a Plan hospital, you will be transferred when
medically feasible with any ambulance charges covered in full.
To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan or
provided by Plan providers
Emergencies outside our service area: Benefits are available for any medically necessary health service that is
immediately required because of injury or unforeseen illness.
If you need to be hospitalized, the Plan must be notified within 24 hours or on the first working day following your
admission, unless it was not reasonably possible to notify the Plan within that time. If a Plan doctor believes care can be
better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in
full.
To be covered by this Plan, any follow-up care recommended by non-Plan providers must be approved by the Plan or
provided by Plan providers.
46 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5(d)
High and Standard Option
Benefit Description You pay
Emergency within our service area High Option Standard Option
• Emergency care at a doctor’s office No deductible
$25 per visit to a primary care
physician
$45 per visit at a specialist
No deductible
$30 per visit to a primary care
physician
$55 per visit at a specialist
• Emergency care at an urgent care center No deductible
$75 per visit
No deductible
$75 per visit
• Emergency care as an outpatient at a hospital,
including doctors’ services
No deductible
$250 per visit
No deductible
$250 per visit
Note: We waive ER copay if you are admitted to
hospital.
Not covered: Elective care or non-emergency care
All charges All charges
Emergency outside our service area High Option Standard Option
• Emergency care at a doctor’s office No deductible
$25 per visit to a primary care
physician
$45 per visit at a specialist
No deductible
$30 per visit to a primary care
physician
$55 per visit at a specialist
Emergency care at an urgent care center No deductible
$75 per visit
No deductible
$75 per visit
• Emergency care as an outpatient at a hospital,
including doctors’ services
Note: We waive ER copay if you are admitted to
hospital.
No deductible
$250 per visit
No deductible
$250 per visit
Not covered:
•
Elective care or non-emergency care and follow-up
care recommended by non-Plan providers that has
not been approved by the Plan or provided by Plan
providers.
•
Emergency care provided outside the service area
if the need for care could have been foreseen
before leaving the service area
•
Medical and hospital costs resulting from a normal
full-term delivery of a baby outside the service area
All charges All charges
47 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5(d)
High and Standard Option
Benefit Description You pay
Ambulance High Option Standard Option
Professional ambulance service when medically
appropriate.
Note: See 5(c) for non-emergency service.
All of our allowable amounts
up to the deductible amount
and nothing thereafter
Deductible applies, then 30%
coinsurance
48 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5(d)
Section 5(e). Mental health and substance abuse benefits
High and Standard Option
When you get our approval for services and follow a treatment plan we approve, cost-sharing and
limitations for Plan mental health and substance abuse benefits will be no greater than for similar
benefits for other illnesses and conditions.
Important things to keep in mind about these benefits:
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary.
•Be sure to read Section 4,
Your costs for covered services
, for valuable information about how cost-
sharing works. Also read Section 9 about coordinating benefits with other coverage, including with
Medicare.
•High Option – The calendar year deductible is $500 per person and $1,000 per family. 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.
•Standard Option - The calendar year deductible is $1,000 per person and $2,000 per family. 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.
•YOU MUST GET PREAUTHORIZATION FOR THESE SERVICES. See the instructions after
the benefits description below.
•OPM will base its review of disputes about treatment plans on the treatment plan's clinical
appropriateness. OPM will generally not order us to pay or provide one clinically appropriate
treatment plan in favor of another.
Benefit Description You pay
Professional Services High Option Standard Option
When part of a treatment plan we approve, we cover
professional services by licensed professional mental
health and substance abuse practitioners when acting
within the scope of their license, such as psychiatrists,
psychologists, clinical social workers, licensed
professional counselors, or marriage and family
therapists.
Diagnosis and treatment of psychiatric conditions,
mental illness, or mental disorders. Services include:
• Diagnostic evaluation
• Crisis intervention and stabilization for acute
episodes
• Medication evaluation and management
(pharmacotherapy)
• Psychological and neuropsychological testing
necessary to determine the appropriate psychiatric
treatment
• Treatment and counseling (including individual or
group therapy visits)
• Diagnosis and treatment of alcoholism and drug
abuse, including detoxification, treatment and
counseling
Nothing Nothing
Professional Services - continued on next page
49 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5(e)
High and Standard Option
Benefit Description You pay
Professional Services (cont.) High Option Standard Option
• Professional charges for intensive outpatient
treatment in a provider’s office or other
professional setting
• Electroconvulsive therapy
Nothing Nothing
Diagnostics High Option Standard Option
• Outpatient diagnostic tests provided and billed by a
licensed mental health and substance abuse
practitioner
• Outpatient diagnostic tests provided and billed by a
laboratory, hospital or other covered facility
• Inpatient diagnostic tests provided and billed by a
hospital or other covered facility
• Nothing
• All of our allowable amounts
up to the deductible amount
and nothing thereafter
• All of our allowable amounts
up to the deductible amount
and nothing thereafter
• Nothing
• Deductible applies, then 30%
coinsurance
• Deductible applies, then 30%
coinsurance
Inpatient hospital or other covered facility High Option Standard Option
Inpatient services provided and billed by a hospital or
other covered facility
• Room and board, such as semiprivate or intensive
accommodations, general nursing care, meals and
special diets, and other hospital services
$100 copayment per hospital
admission after the calendar
year deductible.
Deductible applies, then 30%
coinsurance
Outpatient hospital or other covered facility High Option Standard Option
Outpatient services provided and billed by a hospital
or other covered facility
• Services in approved treatment programs, such as
partial hospitalization, half-way house, residential
treatment, full-day hospitalization, or facility-based
intensive outpatient treatment
$50 copayment per hospital
admission after the calendar
year deductible.
Deductible applies, then 30%
coinsurance
Not covered High Option Standard Option
Services that are not part of a preauthorized approved
plan
All charges All charges
To be eligible to receive these benefits you must obtain a treatment plan and follow all of
the following network authorization processes. To receive a mental health referral, please
call 1-800-752-7242.
Preauthorization
We may limit your benefits if you do not obtain a treatment plan. Limitation
50 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5(e)
Section 5(f). Prescription drug benefits
High and Standard Option
Important things to keep in mind about these benefits:
•We cover prescribed drugs and medications, as described in the chart beginning on the next page.
•Please remember that all benefits are subject to the definitions, limitations and exclusions in this
brochure and are payable only when we determine they are medically necessary.
•Members must make sure their physicians obtain prior approval/authorization for certain
prescription drugs and supplies before coverage applies. Prior approval/authorization must be
renewed periodically.
•No calendar year deductible applies.
•Be sure to read Section 4,
Your costs for covered services,
for valuable information about how cost-
sharing works. Also read Section 9 about coordinating benefits with other coverage, including with
Medicare.
There are important features you should be aware of. These include:
Who can write your prescription. A licensed physician or dentist, and is states allowing it, licensed or certified Physician
Assistant, Nurse Practitioner and Psychologist must prescribe your medication.
Where you can obtain them. You may fill the prescription at a contracted Plan pharmacy or by mail for a maintenance
medication.
We use a formulary. We use a committee of doctors, pharmacists and other health care professionals to develop a formulary
that gives you access to quality medications. FDA-approved brand-name and generic medications are reviewed for safety,
side effects, effectiveness and overall value. We continually update the formulary based on the latest research. If your doctor
prescribes a medication that is not on the list, you can get that medication, but you will share in a greater portion of the cost.
•These are the dispensing limitations. The quantity of each prescription is limited to that sufficient to treat the acute phase
of illness or a 30-day supply maximum, whichever is less, per copayment. Members called to active duty in a time of
national or other emergency who need to obtain a greater than normal supply of prescribed medications should call
866-320-0697.
A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you
receive a name brand drug when a Federally-approved generic drug is available, and your physician has not specified
Dispense as Written for the name brand drug, you have to pay the difference in cost between the name brand drug and the
generic.
Mail Order. You can obtain through Mail Order covered "maintenance" prescription drugs use to treat chronic or long-term
health conditions such as high blood pressure or diabetes for a 90-day supply.
Here are some things to keep in mind about our prescription drug program:
A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you
receive a name brand drug when a Federally-approved generic drug is available, you have to pay the difference in cost
between the name brand drug and the generic.
We administer a formulary. If your physician believes a name brand product is necessary or there is no generic available,
your physician may prescribe a name brand drug from a formulary list. This list of name brand drugs is a preferred list of
drugs that we selected to meet patient needs at a lower cost. To order a prescription drug brochure, call 800-341-6613.
51 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5(f)
High and Standard Option
Benefit Description You pay
Covered medications and supplies High Option Standard Option
We cover the following medications and supplies
prescribed by a Plan physician and obtained from a
Plan pharmacy or through our mail order program:
• Drugs and medicines that by Federal law of the
United States require a physician’s prescription for
their purchase, except as excluded below.
• Insulin
• Insulin syringes and medication
• Disposable needles and syringes for the
administration of covered medications
• Drugs for sexual dysfunction (see Notebelow)
• Growth hormones
Note: Contact the Plan for drug dose limits for sexual
dysfunction.
Note: If there is no generic equivalent available, you
will still have to pay the brand name copay.
Retail Pharmacy
$5 per generic
$40 per name brand formulary
$75 per name brand non-
formulary
Self-Administered Injectible
Drugs
$75 per formulary
$100 per non-formulary
Mail Order (Maintenance
medications only)
$12.50 per generic
$100 per name brand formulary
$187.50 per name brand non-
formulary
Self administered injectables
are not covered in mail order
Retail Pharmacy
$5 per generic
$40 per formulary name brand
$75 per name brand non-
formulary
Self-Administered Injectible
Drugs
$75 per formulary
$100 per non-formulary
Mail Order (Maintenance
medications only)
$12.50 per generic
$100 per name brand formulary
$187.50 per name brand non-
formulary
Self administered injectables
are not covered in mail order
Women's contraceptive drugs and devices Nothing Nothing
Not covered:
•
Drugs and supplies for cosmetic purposes
•
Drugs to enhance athletic performance
•
Fertility drugs
•
Drugs obtained at a non-Plan pharmacy; except for
out-of-area emergencies
•
Vitamins, nutrients and food supplements even if a
physician prescribes or administers them, except
for Vitamin D for adults 65 and older.
•
Nonprescription medicines
Note: Over-the-counter and prescription drugs
approved by the FDA to treat tobacco dependence are
covered under the Tobacco cessation benefit and
require a written prescription by an approved
provider. (See page 24).
All charges All charges
52 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5(f)
Section 5(g). Dental benefits
High and Standard Option
Important things to keep in mind about these benefits:
•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this
brochure and are payable only when we determine they are medically necessary
•If you are enrolled in a Federal Employees Dental/Vision Insurance program (FEDVIP) Dental plan,
your FEHB plan will be First/Primary payor of any Benefits payments and your FEDVIP plan is
secondary to your FEHB plan. See section 9 coordinating benefits with other coverage.
•Plan dentists must provide or arrange your care.
•No calendar year deductible applies.
•We cover hospitalization for dental procedures only when a non-dental physical impairment exists
which makes hospitalization necessary to safeguard the health of the patient. See Section 5(c) for
inpatient hospital benefits. We do not cover the dental procedure unless it is described below.
•Be sure to read Section 4,
Your costs for covered services,
for valuable information about how cost-
sharing works. Also read Section 9 about coordinating benefits with other coverage, including with
Medicare.
Benefit Desription You Pay
Accidental injury benefit High Option Standard Option
We cover restorative services and supplies necessary
to promptly repair (but not replace) sound natural
teeth. The need for these services must result from an
accidental injury.
$25 per visit to a primary care
physician
$45 per visit to a specialist
$30 per visit to a primary care
physician
$55 per visit to a specialist
Dental benefits High Option Standard Option
We have no other dental benefits. All charges All charges
53 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5(g)
Section 5(h). Special features
High and Standard Option
For any of your health concerns, 24 hours a day, 7 days a week, you may call First Help at
800-622-9528 and talk with a registered nurse who will discuss treatment options and
answer your health questions.
24 hour nurse line
This program has something for all members of the family. This is an online Personal
Health Improvement Program. It has programs such as:ePhit, EatPhit, GetPhit, LivePhit,
as well as a Family-Focused Wellness at KidsHealth. Just go to www.mycoventryhealth.
com
Coventry Wellbeing
Program
Under the flexible benefits option, we determine the most effective way to provide
services.
• We may identify medically appropriate alternatives to regular contract benefits as a
less costly alternative. If we identify a less costly alternative, 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).
Flexible benefits option
You can access your personal health record from this website. Print it down and bring it
with you to your Doctor's appointment. www.chcla.com
My Online Services
Gift Card: The Plan has added a drawing for a $100 Visa Gift Card for members who
complete the Health Risk Assessment or enroll in a digital coaching activity in a given
month. Member is also entered into a monthly drawing in which one Coventry member,
federal or non-federal, wins the card. The card can be used for any service at any vendor
that accepts Visa Gift Card.
Health Risk Assessment
Gift Card
54 2015 Coventry Health Care of Louisiana, Inc. High and Standard Option Section 5(g)
Section 5(i). Health education resources and tools
High and Standard Option
Visit the Health Information section of our website at www.chcla.com for information to
help you take command of your health. This section is organized in simple, user-friendly,
sections:
• Assess Your Health – where you will find a simple, free, online health risk assessment
tool to benchmark your wellness, and better understand your overall health status and
risks.
• About Your Health – for information about a specific condition or general preventive
guidelines.
Patient Safety
• WebMD – our link to this health site also provides wellness and disease information to
help improve health.
Prescription Drug
educational materials are also accessible through our website, through
a link to our pharmacy benefit manager, MEDCO. There, you will find:
• Detailed information about a wide range of prescription drugs;
• A drug interaction tool to help easily determine if a specific drug can have any adverse
interactions with each other, with over-the-counter drugs, or with herbals and
vitamins;
• Facts about why FDA-approved generic drugs should be a first choice for effective,
economical treatment.
Another key health information tool that we make available to you is our online quality
tools, powered by HealthShare. You can review the frequency of procedures performed by
a provider, knowing the correlation between frequency of service and quality of outcomes.
We post additional quality outcome information, such as re-admission rates within 30
days, post operative complications, and even death rates.
We also publish an e-newsletter to keep you informed on a variety of issues related to
your good health. Visit our Web site at www.chcla.com for back editions of this
publication, Living Well.
In addition, we augment our health education tools with access to our
Nurse Advisor
Services
. Experienced RNs are available through an inbound call center 24 hours a day,
seven days a week, to assist you and help you to maximize your benefits, by providing
clinical and economic information to make an informed decision on how to proceed with
care. The First Help phone number is 1-800-622-9528.
QuitNet-Tobacco cessation program, QuitNet, which includes individual/group telephonic
counseling, and over the counter (OTC) and prescription drugs approved by the FDA to
treat tobacco dependence.
No cost for counseling for up to two quit attempts per year. No cost for OTC and
prescription drugs approved by the FDA to treat tobacco dependence.
Tobacco cessation program, through QuitNet, including telephonic support, nicotine
replacement therapy, web support, email support, printed Quit Guide and prescription
drug coverage.
Health education
resources and account
management tools
55 2015 Coventry Health Care of Louisiana, Inc. Section 5(i)
High and Standard Option
Should the drug be indicated for multiple purposes, members are required to ask their
doctor to submit a Prior Authorization Form with supporting documentation as to the
indicated use of the medicine/product. All of the over the counter ("OTC") tobacco
cessation products are approved for OTC use in adults 18 years of age or older. Users
under 18 years of age are to consult with their doctor prior to use. Individuals who
continue to smoke, chew tobacco, use snuff or use a nicotine patch or other nicotine
containing products should not use the OTC medication. All OTC products have the same
indication. Enroll online at www.quitnet.com/coventrywellbeing or call 1-866-577-8210.
A representative will ask you for your Authentication code which is your 11 digit
Coventry ID number - and will then assist you in the completion of the registration
process.
Our complex case management programs offer special assistance to members with
intricate, long-term medical needs. Our disease management program fosters a proactive
approach to managing care from prevention through treatment and management. Your
physician can help arranged for participation in these programs, or you can simply contact
our member service department.
Patient safety information is available online at www.chcla.com.
Care support is also available to you, in the form of a relationship that we have established
with the College of American Pathologists for e-mail reminder notifications. We’ll send a
message to the e-mail address you provide on a scheduled basis, reminding you to arrange
for screening tests.
Care support
56 2015 Coventry Health Care of Louisiana, Inc. Section 5(i)
Section 5(j). Non- FEHB benefits available to Plan members
Routine eye exams are covered once every 12 months for $15 copayment through the
Avesis providers. Providers may be found at www.avesis.com or contact customer service
at 800-341-6613.
Vision Care
The benefits on this page 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 towards FEHB deductibles or catastrophic protection out-of-pocket
maximums. These programs and materials are the responsibility of the Plan, and all appeals must follow their guidelines.
For additional information contact the Plan at, 1-800-341-6613 or visit their website at www.chcla.com .
Individual major medical insurance policies are available through CHCLA for dependents who no longer qualify for
coverage under your FEHB benefits plan. Visit our website at www.chcla.com and click the Individual & Families tab in the
middle right of the page with the picture of the two children. At this site you can view individual benefit plan grids, get a
quote and apply online or contact a representative for assistance.
57 2015 Coventry Health Care of Louisiana, Inc. Section 5(i)
Section 6. General exclusions – services, drugs and supplies we do not cover
The exclusions in this section apply to all benefits. There may be other exclusions and limitations listed in Section 5 of
this brochure. Although we may list a specific service as a benefit, we will not cover it unless it is medically necessary
to prevent, diagnose, or treat your illness, disease, injury, or condition. For information on obtaining prior approval for
specific services, such as transplants, see Section 3
When you need prior aproval for certain services.
We do not cover the following:
•Care by non-plan providers except for authorized referrals or emergencies (see Emergency services/accidents);
•Services, drugs, or supplies you receive while you are not enrolled in this Plan;
•Services, drugs, or supplies not medically necessary;
•Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;
•Experimental or investigational procedures, treatments, drugs or devices (see specifics regarding transplants);
•Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were
carried to term, or when the pregnancy is the result of an act of rape or incest;
•Services, drugs, or supplies related to sex transformations;
•Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program;
•Services, drugs, or supplies you receive without charge while in active military service.
•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 part of a 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 cost are generally covered by the clinical trials, this plan
does not cover these costs.
58 2015 Coventry Health Care of Louisiana, Inc. Section 6
Section 7. Filing a claim for covered services
This Section primarily deals with post-service claims (claims for services, drugs or supplies you have already received). See
Section 3 for information on pre-service claims procedures (services, drugs or supplies requiring prior Plan approval),
including urgent care claims procedures. When you see Plan physicians, receive services at Plan hospitals and facilities, or
obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and
pay your copayment, coinsurance, or deductible.
You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these providers
bill us directly. Check with the provider. If you need to file the claim, here is the process:
In most cases, providers and facilities file claims for you. Physicians must file on the form
CMS-1500, Health Insurance Claim Form. Your facility will file on the UB-04 form. For
claims questions and assistance, call us at 800-341-6613, or at our Website at www.chcla.
com.
When you must file a claim – such as for services you receive outside the Plan’s service
area – submit it on the CMS-1500 or a claim form that includes the information shown
below. Bills and receipts should be itemized and show:
• Covered member’s name and date of birth, address, phone number and ID number
• Name and address of the physician or facility that provided the service or supply
• Dates you received the services or supplies
• Diagnosis
• Type of each service or supply
• The charge for each service or supply
• A copy of the explanation of benefits, payments, or denial from any primary payor –
such as the Medicare Summary Notice (MSN)
• Receipts, if you paid for your services
Note: Canceled checks, cash register receipts, or balance due statements are not
acceptable substitutes for itemized bills.
Submit your claims to:
Coventry Health Care of Louisiana
P.O. Box 7707
London, KY 40742
Medical and hospital
benefits
Submit your claims to:
Medco Health Solutions
P.O. Box 14711
London, KY 40512
Prescription drugs
Send us all of the documents for your claim as soon as possible. You must submit the
claim by December 31 of the year after the year you received the service, unless timely
filing was prevented by administrative operations of Government or legal incapacity,
provided the claim was submitted as soon as reasonably possible.
Deadline for filing your
claim
We will notify you of our decision within 30 days after we receive your post-service
claim. If matters beyond our control require an extension of time, we may take up to an
additional 15 days for review 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.
• Post-service claims
procedures
59 2015 Coventry Health Care of Louisiana, Inc. Section 7
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 intial decision, you may ask us to review it by following the
disputed claims process detailed in Section 8 of this brochure.
You may designate an authorized representative to act on your behalf for filing a claim or
to appeal claims decisions to us. For urgent care claims, a health care 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.
Authorized
Representative
If you live in a county where at least 10 percent of the population is literate only in a non-
English language (as determined by the Secretary of Health and Human Services), we will
provide language assistance in that non-English language. You can request a copy of your
Explanation of Benefits (EOB) statement, related correspondence, oral language services
(such as telephone customer assistance), and help with filing claims and appeals
(including external reviews) in the applicable non-English language. The English versions
of your EOBs and related correspondence will include information in the non-English
language about how to access language services in that non-English language.
Any notice of an adverse benefit determination or correspondence from us confirming an
adverse benefit determination will include information sufficient to identify the claim
involved (including the date of service, the health care provider, and the claim amount, if
applicable), and a statement describing the availability, upon request, of the diagnosis and
procedure codes.
Notice Requirements
60 2015 Coventry Health Care of Louisiana, Inc. Section 7
Section 8. The disputed claims process
You may be able to appeal directly to the Office of Personnel Management (OPM) if we do not follow required claims
processes. For more information about situations in which you are entitled to immediately appeal to OPM, including
additional requirements not listed in Sections 3, 7 and 8 of this brochure, please visit www.chcla.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 ned 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 Member Appeals Department by writing 3838 North Causeway Boulevard, Suite 3350,
Metairie, LA 70002 or calling 1-800-341-6613].
Our reconsideration will take into account all comments, documents, records, and other information submitted by you
relating to the claim, without regard to whether such information was submitted or considered in the initial benefit
determination.
When our initial decision is based (in whole or in part) on a medical judgment (i.e., medical necessity, experimental/
investigational), we will consult with a health care professional who has appropriate training and experience in the field of
medicine involved in the medical judgment and who was not involved in making the initial decision.
Our reconsideration decision will not afford deference to the initial decision and will be conducted by a plan representative
who is neither the individual who made the initial decision that is the subject of the reconsideration, nor the subordinate of
that individual.
We will not make our decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect
to any individual (such as a claims adjudicator or medical expert) based upon the likelihood that the individual will support
the denial of benefits.
Ask us in writing to reconsider our initial decision. You must:
a) Write to us within 6 months from the date of our decision; and
b) Send your request to us at: Coventry Health Care of Louisiana, Inc., 3838 North Causeway Blvd., Suite
3350, Metairie, LA 70002; 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) Your email address, if you would like to receive OPM's decision via mail. Please note that by providing
your email address, you may receive OPM's 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 byus 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 decision on reconsideration. You may respond to that new evidence or
rationale at the OPM review stage described in step 4.
1
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
2
61 2015 Coventry Health Care of Louisiana, Inc. Section 8
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 days.
If we do not receive the information within 60 days we will decide within 30 days of the date the information
was due. we will base our decision on the information we already have. We will write to you with our
decision.
If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
• 90 days after the date of our letter upholding our initial decision; or
• 120 days after you first wrote to us -- if we did not answer that request in some way within 30 days; or
• 120 days after we asked for additional information.
Write to OPM at: United States Office of Personnel Management, Healthcaer and Insurance, Federal
Employee Insurance Operations, Health Insurance 3, 1900 E Stree, NW, Washington, DC 20415-3630.
Send OPM the following information:
• A statement about why you believe our decision was wrong, based on specific benefit provisions in htis
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; and
• Copies of all letters we sent to you about the claim; and
• Your daytime phone number and the best time to call.
• Your email address, if you would like to receive OPM's decision via email. Please note that by providing
your email address, you may receive OPM's decision more quickly.
Note: If you want OPM to review more than one claim, you must clearly identify which documents apply to
which claim.
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must include a copy of your specific written consent with the
review request. However, for urgent care claims, a health care professional with knowledge of your medical
condition may act as your authorized representative without your express consent.
Note: The above deadlines may be extended if you show that you were unable to meet the deadline because
of reasons beyond your control.
3
OPM will review your disputed claim request and will use the information it collects from you and us to
decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no
other administrative appeals.
If you do not agree with OPM's decision, your only recourse is to sue. If you decide to file a lawsuit, you
must file the suit against OPM in Federal court by December 31 of the third year after the year in which you
received the disputed services, drugs, or supplies or from the year in which you were denied precertification
or prior approval. This is the only deadline that may not be extended.
OPM may disclose the information it collects during the review process to support their disputed claim
decision. This information will become part of the court record.
You may not file a lawsuit until you have completed the disputed claims process. Further, Federal law
governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record
that was before OPM when OPM decided top uphold or overturn our decision. You may recover only the
amount the benefits in dispute.
4
62 2015 Coventry Health Care of Louisiana, Inc. Section 8
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 1-800-341-6613. 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
Health Insurance 3, at (202) 606-0737 between 8 a.m. and 5 p.m. eastern time.
Please remember that we do not make decisions about plan eligibility issues. For example, we do not
determine whether you or a dependent is covered under this plan.You must raise eligibility issues with your
Agency personnel/payroll office if you are an employee, your retirement system if you are an annuitant or
the Office of Workers' Compensation Programs if you are receiving Workers' Compensation benefits.
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)
245-8327. We will hasten our review (if we have not yet responded to your claim); or we will inform OPM so they can
quickly review your claim on appeal. You may call OPM's Health Insurance at (202) 606-0737 between 8 a.m. and 5 p.m.
Eastern Time.
63 2015 Coventry Health Care of Louisiana, Inc. Section 8
Section 9. Coordinating benefits with other coverage
TRICARE is the health care program for eligible dependents of military persons, and
retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA
provides health coverage to disabled Veterans and their eligible dependents. IF TRICARE
or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA
Health Benefits Advisor if you have questions about these programs.
Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an
annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of
these programs, eliminating your FEHB premium. (OPM does not contribute to any
applicable plan premiums.) For information on suspending your FEHB enrollment,
contact your retirement office. If you later want to re-enroll in the FEHB Program,
generally you may do so only at the next Open Season unless you involuntarily lose
coverage under the program.
TRICARE and
CHAMPVA
We do not cover services that:
You (or a covered family member) need because of a workplace-related illness or injury
that the Office of Workers’ Compensation Programs (OWCP) or a similar Federal or State
agency determines they must provide; or
OWCP or a similar agency pays for through a third-party injury settlement or other similar
proceeding that is based on a claim you filed under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we will
cover your care.
Workers’ Compensation
When you have this Plan and Medicaid, we pay first.
Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored
program of medical assistance: If you are an annuitant or former spouse, you can
suspend your FEHB coverage to enroll in one of these State programs, eliminating your
FEHB premium. For information on suspending your FEHB enrollment, contact your
retirement office. If you later want to re-enroll in the FEHB Program, generally you may
do so only at the next Open Season unless you involuntarily lose coverage under the State
program.
Medicaid
We do not cover services and supplies when a local, State, or Federal government agency
directly or indirectly pays for them.
When other Government
agencies are responsible
for your care
When you receive money to compensate you for medical or hospital care for injuries or
illness caused by another person, you must reimburse us for any expenses we paid.
However, we will cover the cost of treatment that exceeds the amount you received in the
settlement.
If you do not seek damages you must agree to let us try. This is called subrogation. If you
need more information, contact us for our subrogation procedures.
When others are
responsible for injuries
Some FEHB plans already cover some dental and vision services. When you are covered
by more than one vision/dental plan, coverage provided under 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, you will be asked to provide
information on your FEHB plan so that your plans can coordinate benefits. Providing your
FEHB information may reduce your out-of-pocket cost.
When you have Federal
Employees Dental and
Vision Insurance Plan
(FEDVIP) Coverage
64 2015 Coventry Health Care of Louisiana, Inc. Section 9
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, 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.
An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial
that is conducted in relation to the prevention, detection, or treatment of cancer or other
life-threatening disease or condition and is either Federally funded; conducted under an
investigational new drug application reviewed by the Food and Drug Administration; or is
a drug trial that is exempt from the requirement of an investigation 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 visit, lab tests, x-rays and
scans, and hospitalization 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 a clinical trial, but not as a 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 a research
physician, nurse time, analysis of results, and clinical tests performed only for research
purposes. These costs are generally covered by the clinical trials. This plan does not
cover these costs.
Clinical Trials
You must tell us if you or a covered family member has coverage under any other health
plan or have automobile insurance that pays health care expenses without regard to fault.
This is called “double coverage.”
When you have double coverage, one plan normally pays its benefits in full as the primary
payor and the other plan pays a reduced benefit as the secondary payor. We, like other
insurers, determine which coverage is primary according to the National Association of
Insurance Commissioners’ (NAIC) guidelines. For more information on NAIC
rulesregarding the coordinating of benefits, visit the NAIC website at http://www.NAIC.
org.
When we are the primary payor, we will pay the benefits described in this brochure.
When we are the secondary payor, we will determine our allowance. After the primary
plan pays, we will pay what is left of our allowance, up to our regular benefit. We will not
pay more than our allowance.
When you have other
health coverage
When you have Medicare
Medicare is a health insurance program for:
• People 65 years of age or older.
• Some people with disabilities under 65 years of age.
• People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a
transplant).
Medicare has four parts:
• What is Medicare?
65 2015 Coventry Health Care of Louisiana, Inc. Section 9
• Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or your
spouse worked for at least 10 years in Medicare-covered employment, you should be
able to qualify for premium-free Part A insurance. (If you were a Federal employee at
any time both before and during January 1983, you will receive credit for your Federal
employment before January 1983.) Otherwise, if you are age 65 or older, you may be
able to buy it. Contact 1-800-MEDICARE (1-800-633-4227) (TTY 1-877-486-2048)
for more information.
• Part B (Medical Insurance). Most people pay monthly for Part B. Generally, Part B
premiums are withheld from your monthly Social Security check or your retirement
check.
• Part C (Medicare Advantage). You can enroll in a Medicare Advantage plan to get
your Medicare benefits. We do not offer a Medicare Advantage plan. Please review the
information on coordinating benefits with Medicare Advantage plans on the next page.
• Part D (Medicare prescription drug coverage). There is a monthly premium for Part D
coverage. Before enrolling in Medicare Part D, please review the important disclosure
notice from us about the FEHB prescription drug coverage and Medicare. The notice
is on the first inside page of this brochure. For people with limited income and
resources, extra help in paying for a Medicare prescription drug plan is available. For
more information about this extra help, visit SSA online at www.socialsecurity.gov, or
call them at 1-800-772-1213 (TTY 1-800-325-0778).
The decision to enroll in Medicare is yours. We encourage you to apply for Medicare
benefits 3 months before you turn age 65. It’s easy. Just call the Social Security
Administration toll-free number 1-800-772-1213 (TTY 1-800-325-0778) to set up an
appointment to apply. If you do not apply for one or more Parts of Medicare, you can still
be covered under the FEHB Program.
If you can get premium-free Part A coverage, we advise you to enroll in it. Most Federal
employees and annuitants are entitled to Medicare Part A at age 65 without cost. When
you don’t have to pay premiums for Medicare Part A, it makes good sense to obtain the
coverage. It can reduce your out-of-pocket expenses as well as costs to the FEHB, which
can help keep FEHB premiums down.
Everyone is charged a premium for Medicare Part B coverage. The Social Security
Administration can provide you with premium and benefit information. Review the
information and decide if it makes sense for you to buy the Medicare Part B coverage. If
you didn't take Part B at age 65 because you were covered under FEHB as an active
employee (or you were covered under your spouse's group health insurance plan and he/
she was an active employee), you may sign up for Part B (generally without an increased
premium) within 8 months from the time you or your spouse stop working or are no
longer covered by the group plan. You also can sign up at any time while you are covered
by the group plan.
If you are eligible for Medicare, you may have choices in how you get your health care.
Medicare Advantage is the term used to describe the various private health plan choices
available to Medicare beneficiaries. The information in the next few pages shows how we
coordinate benefits with Medicare, depending on whether you are in the Original
Medicare Plan or a private Medicare Advantage plan.
• Should I enroll in
Medicare?
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. Some things are not covered under Original Medicare, such as most
prescription drugs (but coverage through private prescription drug plans is available
starting in 2006).
• The Original
Medicare Plan (Part
A or Part B)
66 2015 Coventry Health Care of Louisiana, Inc. Section 9
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 probably will never
have to file a claim form when you have both our Plan and the Original Medicare Plan.
When we are the primary payor, we process the claim first.
When Original Medicare is the primary payor, Medicare processes your claim first. In
most cases, your claim will be coordinated automatically and we will then provide
secondary benefits for covered charges.
You can find more information about how our plan coordinates benefits with Medicare at
www.chcla.com.
You must tell us if you or a covered family member has Medicare coverage, and let us
obtain information about services denied or paid under Medicare if we ask. You must also
tell us about other coverage you or your covered family members may have, as this
coverage may affect the primary/secondary status of this Plan and Medicare.
• Tell us about your
Medicare coverage
If you are eligible for Medicare, you may choose to enroll in and get your Medicare
benefits from a Medicare Advantage plan. These are private health care choices (like
HMOs and regional PPOs) in some areas of the country. To learn more about Medicare
Advantage plans, contact Medicare at 1-800-MEDICARE (1-800-633-4227), (TTY
1-877-486-2048) or at www.medicare.gov.
If you enroll in a Medicare Advantage plan, the following options are available to you:
This Plan and another plan’s Medicare Advantage plan: You may enroll in another
plan’s Medicare Advantage plan and also remain enrolled in our FEHB plan. We will still
provide benefits when your Medicare Advantage plan is primary, even out of the Medicare
Advantage plan’s network and/or service area (if you use our Plan providers). However
we will not waive any of our copayments, coinsurance, or deductibles. If you enroll in a
Medicare Advantage plan, tell us. We will need to know whether you are in the Original
Medicare Plan or in a Medicare. Advantage plan so we can correctly coordinate benefits
with Medicare.
Suspended 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 Advantage
(Part C)
When we are the primary payor, we process the claim first. If you enroll in Medicare Part
D and we are the secondary payor, we will review claims for your prescription drug costs
that are not covered by Medicare Part D and consider them for payment under the FEHB
plan.
• Medicare prescription
drug coverage (Part
D)
67 2015 Coventry Health Care of Louisiana, Inc. Section 9
Medicare always makes the final determination as to whether they are the primary payor. The following chart illustrates
whether Medicare or this Plan should be the primary payor for you according to your employment status and other factors
determined by Medicare. It is critical that you tell us if you or a covered family member has Medicare coverage so we can
administer these requirements correctly. (Having coverage under more than two health plans may change the order of
benefits determined on this chart.)
Primary Payor Chart
A. When you - or your covered spouse - are age 65 or over and have Medicare and you... The primary payor for the
individual with Medicare is...
Medicare This Plan
1) Have FEHB coverage on your own as an active employee
2) Have FEHB coverage on your own as an annuitant or through your spouse who is an
annuitant
3) Have FEHB through your spouse who is an active employee
4) Are a reemployed annuitant with the Federal government and your position is excluded from
the FEHB (your employing office will know if this is the case) and you are not covered under
FEHB through your spouse under #3 above
5) Are a reemployed annuitant with the Federal government and your position is not excluded
from the FEHB (your employing office will know if this is the case) and...
• You have FEHB coverage on your own or through your spouse who is also an active
employee
• You have FEHB coverage through your spouse who is an annuitant
6) Are a Federal judge who retired under title 28, U.S.C., or a Tax Court judge who retired
under Section 7447 of title 26, U.S.C. (or if your covered spouse is this type of judge) and
you are not covered under FEHB through your spouse under #3 above
7) Are enrolled in Part B only, regardless of your employment status
for Part B
services
for other
services
8) Are a Federal employee receiving Workers' Compensation disability benefits for six months
or more
*
B. When you or a covered family member...
1) Have Medicare solely based on end stage renal disease (ESRD) and...
• It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD
(30-month coordination period)
• It is beyond the 30-month coordination period and you or a family member are still entitled
to Medicare due to ESRD
2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary and...
• This Plan was the primary payor before eligibility due to ESRD (for 30 month
coordination period)
• Medicare was the primary payor before eligibility due to ESRD
3) Have Temporary Continuation of Coverage (TCC) and...
• Medicare based on age and disability
• Medicare based on ESRD (for the 30 month coordination period)
• Medicare based on ESRD (after the 30 month coordination period)
C. When either you or a covered family member are eligible for Medicare solely due to
disability and you...
1) Have FEHB coverage on your own as an active employee or through a family member who
is an active employee
2) Have FEHB coverage on your own as an annuitant or through a family member who is an
annuitant
D. When you are covered under the FEHB Spouse Equity provision as a former spouse
*Workers' Compensation is primary for claims related to your condition under Workers' Compensation.
68 2015 Coventry Health Care of Louisiana, Inc. Section 9
Section 10. Definitions of terms we use in this brochure
January 1 through December 31 of the same year. For new enrollees, the calendar year
begins on the effective date of their enrollment and ends on December 31 of the same
year.
Calendar year
An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial
that is conducted in relation to the prevention, detection, or treatment of cancer or other
life-threatening disease or condition and is either Federally funded; conducted under an
investigational new drug application reviewed by the Food and Drug Administration; or is
a drug trial that is exempt from the requirement of an investigational new drug
application.
• Routine care costs - costs for routine services such as doctor visits, lab tests, x-ray 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 a part of the patient's routine
care.
• Research costs - costs related to conducting the clinical trial such as research
physician, nurse time, analysis of results, and clinical tests performed only for research
purposes. These costs are generally covered by the clinical trials. This plan does not
cover these costs.
Clinical Trials Cost
Categories
Coinsurance is the percentage of our allowance that you must pay for your care. You may
also be responsible for additional amounts.
Coinsurance
A copayment is a fixed amount of money you pay when you receive covered services. Copayment
Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible,
coinsurance, and copayments) for the covered care you receive.
Cost-sharing
Care we provide benefits for, as described in this brochure. Covered services
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.
Deductible
A health product or service is deemed experimental or investigational and excluded from
coverage under this Agreement if one or more of the following conditions are met: (i) any
drug not approved for use by the FDA; any drug that is classified as IND (investigational
new drug) by the FDA; (ii) any drug requiring pre-authorization that is proposed for off-
label prescribing; (iii)any health product or service that is subject to Investigational
Review Board (IRB) review or approval; (iv) any health product or service that is subject
of a clinical trial that meets criteria for Phase I, II or III as set forth by FDA regulations; or
(v) any health product or service that does not have a demonstrated value based on clinical
evidence reported by peer-review medical literature and by generally recognized academic
experts.
Experimental or
investigational service
If you leave the FEHB Program, we will give you a Certificate of Group Health Plan
Coverage that indicates how long you have been enrolled with us. You can use this
certificate when getting health insurance or other health care coverage. You must arrange
for the other coverage within 63 days of leaving this Plan. Your new plan must reduce or
eliminate waiting periods, limitations or exclusions for health related conditions based on
the information in the certificate.
If you have been enrolled with us for less than 12 months, but were previously enrolled in
other FEHB plans, you may request a certificate from them, as well.
Group health coverage
69 2015 Coventry Health Care of Louisiana, Inc. Section 10
A physician or other health care professional licensed, accredited, or certified to perform
specified health services consistent with state law.
Health care professional
Plan allowance is the amount we use to determine our payment and your coinsurance for
covered services. Plans determine their allowances in different ways. We determine our
allowance as follows:
Plan allowance
Any claims that are not pre-service claims. In other words, post service claims are those
claims where treatment has been performed and the claims have been sent to us in order to
apply for benefits.
Post-service claims
Those claims (1) that require precertification, prior approval, or a referral and (2) where
failure to obtain precertification, prior approval, or a referral results in a reduction of
benefits.
Pre-service claims
A physician or other health care professional licensed, accredited, or certified to perform
specified health services consistent with state law.
A claim for medical care or treatment is an urgent care claim if waiting for the regular
time limit for non-urgent care claims could have one of the following impacts:
• Waiting could seriously jeopardize your life or health
• Waiting could seriously jeopardize your ability to regain maximum function; or
• In the opinion of a physician with knowledge of your medical condition, waiting
would subject you to severe pain that cannot be adequately managed without the care
or the treatment that is the subject of the claim.
Urgent care claims largely involve claims for access to care rather than claims for care
that has already been rendered. We will judge whether a claim is an urgent care claim by
applying the judgement of a prudent layperson who possesses an average knowledge of
health and medicine.
If you believe your claim qualifies as an urgent care claim, you should notify us when you
submit the claim. You may also prove that your claim is an urgent claim by providing
evidence that a physician with knowledge of your medical condition has determined that
your claim involves urgent care.
Urgent care claims
Us and We refer to Coventry Health Care of Louisiana, Inc. Us/We
You refers to the enrollee and each covered family member. You
70 2015 Coventry Health Care of Louisiana, Inc. Section 10
Section 11. Other Federal Programs
Please note, the following programs are not part of your FEHB benefits. They are separate Federal programs that
complement your FEHB benefits and can potentially reduce your annual out-of-pocket expenses. These programs are offered
independent of the FEHB Program and require you to enroll separately with no Government contribution.
First, the Federal Flexible Spending Account Program, also known as FSAFEDS, lets
you set aside pre-tax money from your salary to reimburse you for eligible dependent care
and health care expenses. You pay less in taxes and save money. The result can be a
discount of 20% to more than 40% on services/products you routinely pay for out-of-
pocket.
Second, the Federal Employees Dental and Vision Insurance Program (FEDVIP),
provides comprehensive dental and vision insurance at competitive group rates. There are
several plans from which to chose. Under FEDVIP you may choose self only, self plus
one, or self and family coverage for yourself and any eligible dependents.
Third, the Federal Long Term Care Insurance Program (FLTCIP) helps cover long
term care costs, which are not covered under the FEHB Program.
Important information
about three Federal
programs that
complement the FEHB
Program
The Federal Flexible Spending Account Program –
FSAFEDS
It is an account where you contribute money from your salary BEFORE taxes are
withheld, then incur eligible expenses and get reimbursed. You pay less in taxes so you
save money. Annuitants are not eligible to enroll.
There are three types of FSAs offered by FSAFEDS. Each type has a minimum annual
election of $100. The maximum annual election for a health care flexible spending
account (HCFSA) or a limited expense health care spending account (LEX HCFSA) is
$2,500.
• Health Care FSA (HCFSA) – Reimburses you for eligible out-of-pocket health care
expenses (such as copayments, deductibles, prescriptions, physician prescribed over-
the-counter medications, vision and dental expenses, and much more) for you and
your tax dependents, including adult children (through the end of the calendar year in
which they turn 26).
FSAFEDS offers paperless reimbursement for your HCFSA through a number of FEHB
and FEDVIP plans. This means that when you or your provider files claims with your
FEHB or FEDVIP plan, FSAFEDS will automatically reimburse your eligible out-of-
pocket expenses based on the claim information it receives from your plan.
• Limited Expense Health Care FSA (LEX HCFSA) – Designed for employees
enrolled in or covered by a High Deductible Health Plan with a Health Savings
Account. Eligible expenses are limited to out-of-pocket dental and vision care
expenses for you and your tax dependents including adult children (through the end of
the calendar year in which they turn 26)
• Dependent Care FSA (DCFSA) – Reimburses you for eligible nonmedical day care
expenses for your children under age 13 and/or for any person you claim as a
dependent on your Federal Income Tax return who is mentally or physically incapable
of self-care. You (and your spouse if married) must be working, looking for work
(income must be earned during the year), or attending school full-time to be eligible
for a DCFSA.
• If you are a new or newly eligible employee you have 60 days from your hire date to
enroll in an HCFSA or LEX HCFSA and/or DCFSA, but you must enroll before
October 1. If you are hired or become eligible on or after October 1 you must wait
and enroll during the Federal Benefits Open Season held each fall.
What is an FSA?
71 2015 Coventry Health Care of Louisiana, Inc. Section 11
Visit www.FSAFEDS.com or call an FSAFEDS Benefits Counselor toll-free at 1-877-
FSAFEDS (1-877-372-3337), Monday through Friday, 9 a.m. until 9 p.m., Eastern Time.
TTY: 1-800-952-0450.
Where can I get more
information about
FSAFEDS?
The Federal Empolyees Dental and Vision Insurance Program –
FEDVIP
The Federal Employees Dental and Vision Insurance Program (FEDVIP) is separate and
different from the FEHB Program, and was established by the Federal Employee Dental
and Vision Benefits Enhancement Act of 2004. This program provides comprehensive
dental and vision insurance at competitive group rates with no pre-existing condition
limitations for enrollment.
FEDVIP is available to eligible Federal and Postal service employees, retirees, and their
eligible family members on an enrollee-pay-all basis. Employee premiums are withheld
from salary on a pre-tax basis.
Important Information
All dental plans provide a comprehensive range of services, including:
• Class A (Basic) services, which include oral examinations, prophylaxis, diagnostic
evaluations, sealants and x-rays.
• Class B (Intermediate) services, which include restorative procedures such as fillings,
prefabricated stainless steel crowns, periodontal scaling, tooth extractions, and denture
adjustments.
• Class C (Major) services, which include endodontic services such as root canals,
periodontal services such as gingivectomy, major restorative services such as crowns,
oral surgery, bridges and prosthodontic services such as complete dentures.
• Class D (Orthodontic) services with up to 12-month waiting period. Most FEDVIP
dental plans coverage adult orthodontia. Review your FEDVIP dental plan's
brochure for information on this benefit.
Dental Insurance
All vision plans provide comprehensive eye examinations and coverage for lenses, frames
and contact lenses. Other benefits such as discounts on LASIK surgery may also be
available.
Vision Insurance
You can find a comparison of the plans available and their premiums on the OPM website
at www.opm.gov/insure/vision. These sites also provide links to each plan’s website,
where you can view detailed information about benefits and preferred providers.
Additional Information
You enroll on the Internet at www.BENEFEDS.com. For those without access to a
computer, call 1-877-889-3337 (TTY 1-877-889-5680).
How do I enroll?
The Federal Long Term Care Insurance Program –
FLTCIP
The Federal Long Term Care Insurance Program (FLTCIP) can help pay for the
potentially high cost of long term care services, which are not covered by FEHB plans.
Long term care is help you receive to perform activities of daily living – such as bathing
or dressing yourself - or supervision you receive because of a severe cognitive impairment
such as Alzheimer’s disease. For example, long term care can be received in your home
from a home health aide, in a nursing home, in an assisted living facility or in adult day
care. To qualify for coverage under the FLTCIP, you must apply and pass a medical
screening (called underwriting). Federal and U.S. Postal Service employees and
annuitants, active and retired members of the uniformed services, and qualified relatives,
are eligible to apply. Certain medical conditions, or combinations of conditions, will
prevent some people from being approved for coverage. You must apply to know if you
will be approved for enrollment. For more information, call 1-800-LTC-FEDS
(1-800-582-3337) (TTY 1-800-843-3557) or visit www.ltcfeds.com.
It’s important protection
72 2015 Coventry Health Care of Louisiana, Inc. Section 11
Index
Accidental injury ......................................52
Allergy tests ...............................................28
Allogeneic (donor) bone marrow transplant
..............................................................37
Alternative treatments ................................53
Ambulance .................................................43
Anesthesia ..................................................33
Autologous bone marrow transplant ..........28
Biopsy ........................................................33
Blood and blood plasma .............................43
Casts ..........................................................43
Catastrophic protection out-of-pocket
maximum ...................................................74
Changes for 2015 .......................................13
Chemotherapy ............................................28
Chiropractic ................................................31
Colorectal cancer screening .......................25
Congenital anomalies .................................33
Contraceptive drugs and devices ...............51
Cost Sharing ...............................................52
Dental care ................................................36
Disputed claims review ..............................53
Donor expenses .....................................26,27
Durable medical equipment .......................31
Emergency ................................................46
Experimental or investigational .................57
Eyeglasses ..................................................29
Family planning .......................................27
Fecal occult blood test ...............................24
Fraud ............................................................3
General exclusions ...................................57
Hearing services .......................................29
Home health services .................................31
Hospice care ...............................................45
Immunizations ..........................................25
Infertility ....................................................27
Inpatient hospital benefits ..........................43
Insulin ........................................................51
Magnetic Resonance Imagings (MRIs)
..............................................................24
Mammograms ............................................24
Maternity benefits ......................................26
Medicaid ....................................................63
Medically necessary ...................................15
Medicare ....................................................64
Mental Health/Substance Abuse Benefits
..............................................................48
Newborn care ...........................................26
Non-FEHB benefits ...................................56
Nurse Anesthetist (NA) ..............................43
Occupational therapy ..............................28
Office visits ................................................24
Oral and maxillofacial surgical ..................35
Original Medicare Plan ..............................65
Outpatient ...................................................44
Oxygen .......................................................31
Pap test ......................................................24
Precertification ...........................................33
Prescription drugs ......................................50
Preventive care services .............................25
Preventive care, adult .................................25
Preventive care, children ............................26
Prior approval .............................................18
Prosthetic devices .......................................29
Radiation therapy ....................................28
Reconstructive ............................................33
Room and board .........................................43
Second surgical opinion ...........................24
Skilled nursing facility care .......................42
Speech therapy ...........................................29
Subrogation ................................................63
Substance abuse .........................................48
Temporary Continuation of Coverage
(TCC) ..................................................10
Transplants .................................................36
Treatment therapies ....................................28
Vision care .................................................56
Vision services ...........................................56
Workers Compensation ...........................62
X-rays ........................................................24
73 2015 Coventry Health Care of Louisiana, Inc. Index
Summary of benefits for the High Option of Coventry Health Care of Louisiana
2015
•Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions ,
limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look
inside.
•If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on
your enrollment form.
•We only cover services provided or arranged by Plan physicians, except in emergencies.
•Below, some services indicate deductible applies to the $500 per person and $1,000 family calendar year deductible.
High Option Benefits You pay Page
Medical services provided by physicians:
Office visit copay: $25 primary care; $45
specialist
24 Diagnostic and treatment services provided in the office
Services provided by a hospital:
$100 copayment per hospital admission after
the calendar year deductible.
43 • Inpatient
$50 copayment for the facility charge after the
calendar year deductible.
44 • Outpatient
Emergency benefits:
$250 per Emergency Room visit/$75 per
Urgent Care Center visit
47 • In-area
$250 per Emergency Room visit/$75 per
Urgent Care Center visit
47 • Out-of-area
Regular cost-sharing 48 Mental health and substance abuse treatment:
Prescription drugs:
$5 generic, $40 brand name, $75 non-
formulary
50 • Retail pharmacy
$75 per formulary, $100 per non-formulary 50 • Self-administered injectible drugs
$12.50 generic, $100 brand name, $187.50
non-formulary
Self-administered injectables are not covered
in mail order
50 • Mail order
No benefit 52 Dental care:
$15 copay 56 Vision care through Avesis:
24 hour nurse line; Coventry WellBeing;
Flexible benefits option; My Online Services;
$100 Visa gift card drawing
53 Special features:
Nothing after $3,000/Self Only or $6,000/
Family enrollment per year . Some costs do
not count toward this protection
74 Protection against catastrophic costs (out-of-pocket
maximum):
74 2015 Coventry Health Care of Louisiana, Inc. High Option Summary
Summary of benefits for the Standard Option of Coventry Health Care of Louisiana
2015
•Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions,
limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail, look
inside.
•If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the cover on
your enrollment form.
•We only cover services provided or arranged by Plan physicians, except in emergencies.
•Below, an asterisk (*) means the item is subject to the $1,000 self only and $2,000 family calendar year deductible.
Standard Option Benefits You Pay Page
Medical services provided by physicians:
Office visit copay: $30 primary care; $55
specialist
24 Diagnostic and treatment services provided in the office
Services provided by a hospital:
Deductible applies, then 30% coinsurance 43 • Inpatient
Deductible applies, then 30% coinsurance 44 • Outpatient
Emergency benefits:
$250 per Emergency Room visit/$75 per
Urgent Care Center visit
47 • In-area
$250 per Emergency Room visit/$75 per
Urgent Care Center visit
47 • Out-of-area
Regular cost-sharing 48 Mental health and substance abuse treatment:
Prescription drugs:
$5 generic, $40 brand name, $75 non-
formulary
50 • Retail pharmacy
$75 per formulary, $100 per non-formulary 50 • Self-administered injectible drugs
$12.50 generic, $100 brand name, $187.50
non-formulary
Self-administered injectables are not covered
in mail order
50 • Mail order
No benefit 52 Dental care:
$15 copay 56 Vision care through Avesis:
24 hour nurse line; Coventry WellBeing;
Flexible benefits option; My Online Services;
$100 Visa gift card drawing
53 Special features:
Nothing after $4,000/Self Only or $8,000
Family enrollment per year
Some costs do not count toward this
protection
74 Protection against catastrophic costs (out-of-pocket
maximum):
75 2015 Coventry Health Care of Louisiana, Inc. Standard Option Summary
Notes
76 2015 Coventry Health Care of Louisiana, Inc. Standard Option Summary
Notes
77 2015 Coventry Health Care of Louisiana, Inc.
2015 Rate Information for Coventry Health Care of Louisiana
Non-postal rates apply to most non-Postal employees. If you are in a special enrollment category, refer to the
Guide to
Federal Benefits
for that category or contact the agency that maintains your health benefits enrollment.
Postal rates apply to Postal Service employees. They are shown in special Guides published for APWU (including Material
Distribution Center and Operatomg Services) NALC, NPMHU and NRLCA Career Postal Employees (see RI 70-2A);
Information Technology/Accounting Services employees (see RI 70-21T); Nurses (see RI 70-2N); Postal Service Inspectors
and Office of Inspector General (OIG) law enforcement employees and Posal Career Executive Service employees (see
RI-70-2IN); and non-career employees (see RI 70-8PS).
Postal Category 1 applies to career employees who are members of the APWY, NALC, NPMHU, or NRLCA bargaining
unites.
Postal Category 2 rates apply to career non-bargaining unit, non-executive, non-law enforcement employees, and non-law
enforcement Inspection Service and Forensics employees.
For further assistance, Postal Service employees should call:
Human Resources Shared Service Center
1-877-477-3272, option 5
TTY: 1-866-260-7507
Postal rates do not apply to non-career postal employees, postal retirees, or associate members of any postal employee
organization who are not career postal employees. Refer to the applicable Guide to Federal Benefits.
Premiums for Tribal employees are shown under the monthly non-postal 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.
Type of
Enrollment
Enrollment
Code
Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Gov't
Share
Your
Share
Gov't
Share
Your
Share
Category 1
Your Share
Category 2
Your Share
New Orleans
High Option Self
Only
BJ1 $202.01 $131.09 $437.69 $284.03 $117.06 $131.09
High Option Self
and Family
BJ2 $448.57 $324.99 $971.90 $704.15 $293.84 $324.99
Standard Option
Self Only
BJ4 $196.30 $65.43 $425.31 $141.77 $51.69 $65.43
Standard Option
Self and Family
BJ5 $448.57 $159.29 $971.70 $345.13 $128.14 $159.29
