Coventry Health Plan of Florida

http://www.chcflorida.com

Customer service 1-800-575-1882

2013

A Health Maintenance Organization (High and Standard Option), and a

high deductible health plan

IMPORTANT

• Rates: Back Cover

• Changes for 2013: Page 14

• Summary of benefits: Page 117

Serving: South Florida (Broward, Miami-Dade, Martin, Palm

Beach and St. Lucie counties)

Enrollment in this plan is limited. You must live or work in our

Geographic service area to enroll. See page 13 for requirements.

Enrollment code for this Plan:

5E1 High Option - Self Only

5E2 High Option - Self and Family

5E4 Standard Option - Self Only

5E5 Standard Option - Self and Family

J41 High Deductible Health Plan (HDHP) - Self Only

J42 High Deductible Health Plan (HDHP) - Self and Family

RI 73-683

Important Notice from Coventry Health Plan of Florida About

Our Prescription Drug Coverage and Medicare

OPM has determined that the Coventry Health Plan of Florida 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. Thus you do not need to enroll in Medicare Part D and pay extra for prescription drug benefit 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 your FEHB plan will

coordinate benefits with Medicare.

Remember: If you are an annuitant and you cancel your FEHB coverage, you may not re-enroll in the FEHB Program.

Please be advised

If you lose or drop your FEHB coverage and go 63 days or longer without prescription drug coverage that’s as least as good

as Medicare’s prescription drug coverage, your monthly premium will go up a least 1% per month for every month that you

did not have that coverage. For example, if you go 19 months without Medicare Part D prescription drug coverage, your

premium will always be at least 19 percent higher than what many other people pay. You’ll have to pay this higher premium

as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the Annual Coordinated

Election Period (October 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

Table of Contents ..........................................................................................................................................................................1

Introduction ...................................................................................................................................................................................3

Plain Language ..............................................................................................................................................................................3

Stop Health Care Fraud! ...............................................................................................................................................................3

Preventing Medical Mistakes ........................................................................................................................................................4

FEHB Facts ...................................................................................................................................................................................7

Coverage information .........................................................................................................................................................7

• No pre-existing condition limitation ...............................................................................................................................7

• Where you can get information about enrolling in the FEHB Program .........................................................................7

• Types of coverage available for you and your family ....................................................................................................7

• Children's Equity Act ......................................................................................................................................................8

• When benefits and premiums start .................................................................................................................................9

• When you retire ..............................................................................................................................................................9

When you lose benefits .......................................................................................................................................................9

• When FEHB coverage ends ............................................................................................................................................9

• Upon divorce ................................................................................................................................................................10

• Temporary Continuation of Coverage (TCC) ...............................................................................................................10

• Converting to individual coverage ...............................................................................................................................10

• Getting a Certificate of Group Health Plan Coverage ..................................................................................................10

Section 1. How this plan works ...................................................................................................................................................11

How we pay providers ......................................................................................................................................................11

Your rights .........................................................................................................................................................................13

Service Area ......................................................................................................................................................................13

Section 2. Changes for 2013 .......................................................................................................................................................14

Changes to this Plan ..........................................................................................................................................................14

Section 3. How you get care .......................................................................................................................................................15

Identification cards ............................................................................................................................................................15

Where you get covered care ..............................................................................................................................................15

• Plan providers ...............................................................................................................................................................15

• Plan facilities ................................................................................................................................................................15

What you must do to get covered care ..............................................................................................................................15

• Primary care ..................................................................................................................................................................15

• Specialty care ................................................................................................................................................................15

• Hospital care .................................................................................................................................................................16

• If you are hospitalized when your enrollment begins ...................................................................................................16

You need prior Plan approval for certain services ............................................................................................................16

• Inpatient hospital services ............................................................................................................................................16

• Other services ...............................................................................................................................................................16

How to request precertification for an admission or get prior authorization for Other services ......................................18

• Non-urgent care claims .................................................................................................................................................18

• Urgent care claims ........................................................................................................................................................18

• Emergency inpatient admission ....................................................................................................................................19

• If your treatment needs to be extended .........................................................................................................................19

What happens when you do not follow the precertification rules when using non-network facilities .............................19

• To reconsider a non-urgent care claim ..........................................................................................................................19

• To reconsider an urgent care claim ...............................................................................................................................19

1 2013 Coventry Health Plan of Florida Table of Contents

• To file an appeal with OPM ..........................................................................................................................................20

Section 4. Your cost for covered services ...................................................................................................................................21

Copayments .......................................................................................................................................................................21

Deductible .........................................................................................................................................................................21

Your catastrophic protection out-of-pocket maximum .....................................................................................................21

Section 5. High and Standard Option Benefits Overview ..........................................................................................................25

Non-FEHB benefits available to Plan members .........................................................................................................................98

Section 6. General exclusions – services, drugs and supplies we do not cover ..........................................................................99

Section 7. Filing a claim for covered services ..........................................................................................................................100

Section 8. The disputed claims process .....................................................................................................................................102

Section 9. Coordinating benefits with Medicare other coverage ..............................................................................................105

When you have other health coverage ............................................................................................................................105

TRICARE and CHAMPVA ............................................................................................................................................105

Workers' Compensation ..................................................................................................................................................105

Medicaid ..........................................................................................................................................................................105

When other Government agencies are responsible for your care ...................................................................................105

When others are responsible for injuries .........................................................................................................................106

What is Medicare? ..........................................................................................................................................................106

• Should I enroll in Medicare? ......................................................................................................................................107

• The Original Medicare Plan (Part A or Part B) ...........................................................................................................107

• Medicare Advantage (Part C) .....................................................................................................................................108

• Medicare prescription drug coverage (Part D) ...........................................................................................................108

Section 10. Definitions of terms we use in this brochure ..........................................................................................................110

Section 11. Other Federal Programs ..........................................................................................................................................112

The Federal Flexible Spending Account Program - FSAFEDS ......................................................................................112

The Federal Employees Dental and Vision Insurance Program - FEDVIP ....................................................................114

The Federal Long Term Care Insurance Program - FLTCIP ...........................................................................................114

The Pre-Exisitng Condition Insurance Plan (PCIP) ........................................................................................................115

Index ..........................................................................................................................................................................................116

Summary of benefits for the High Option of Coventry Health Plan of Florida 2013 ...............................................................117

Summary of benefits for the Standard Option of Coventry Health Plan of Florida 2013 .........................................................118

Summary of benefits for the HDHP for Coventry Health Plan of Florida 2013 .......................................................................119

2013 Rate Information for the Coventry Health Plan of Florida ..............................................................................................120

2 2013 Coventry Health Plan of Florida Table of Contents

Introduction

This brochure describes the benefits of Coventry Health Plan of Florida, Inc.under our contract (CS 2715) with the United

States Office of Personnel Management, as authorized by the Federal Employees Health Benefits law. Customer service may

be reached at 1/866-575-1882 or through our website: www.feds.chcflorida.com. The address for Coventry Health Plan of

Florida, Inc. administrative offices is:

Coventry Health Care of Florida, Inc.

1340 Concord Terrace

Sunrise Florida 33323

This brochure is the official statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations,

and exclusions of this brochure. It is your responsibility to be informed about your health benefits.

If you are enrolled in this Plan, you are entitled to the benefits described in this brochure. If you are enrolled in Self and

Family coverage, each eligible family member is also entitled to these benefits. You do not have a right to benefits that were

available before January 1, 2013, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2013, and changes are

summarized on page 14. Rates are shown at the end of this brochure.

Plain Language

All FEHB brochures are written in plain language to make them easy to understand. Here are some examples,

•Except for necessary technical terms, we use common words. For instance, “you” means the enrollee or family member,

“we” means Coventry Health Plan of Florida, Inc.

•We limit acronyms to ones you know. FEHB is the Federal Employees Health Benefits Program. OPM is the United States

Office of Personnel Management. If we use others, we tell you what they mean first.

•Our brochure and other FEHB plans’ brochures have the same format and similar descriptions to help you compare plans.

Stop Health Care Fraud!

Fraud increases the cost of health care for everyone and increases your Federal Employees Health Benefits Program

premium.

OPM’s Office of the Inspector General investigates all allegations of fraud, waste, and abuse in the FEHB Program

regardless of the agency that employs you or from which you retired.

Protect Yourself From Fraud – Here are some things that you can do to prevent fraud:

•Do not give your plan identification (ID) number over the telephone or to people you do not know, except for your health

care providers, authorized health benefits plan, or OPM representative.

•Let only the appropriate medical professionals review your medical record or recommend services.

•Avoid using health care providers who say that an item or service is not usually covered, but they know how to bill us to

get it paid.

•Carefully review explanations of benefits (EOBs) statements that you receive from us.

•Periodically review your claim history for accuracy to ensure we have not been billed for services that you did not receive.

•Do not ask your doctor to make false entries on certificates, bills or records in order to get us to pay for an item or service.

•If you suspect that a provider has charged you for services you did not receive, billed you twice for the same service, or

misrepresented any information, do the following:

- Call the provider and ask for an explanation. There may be an error.

3 2013 Coventry Health Plan of Florida Introduction/Plain Language/Advisory

- If the provider does not resolve the matter, call us at (866) 575-1882 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, DC 20415-1100

•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 is disabled and incapable of self-support prior to age 26)

•If you have any questions about the eligibility of a dependent, check with your personnel office if you are employed, with

your retirement office (such as OPM) if you are retired, or with the National Finance Center if you are enrolled under

Temporary Continuation of Coverage.

•Fraud or intentional misrepresentation of material fact is prohibited under the Plan. You can be prosecuted for fraud and

your agency may take action against you. Examples of fraud include, falsifying a claim to obtain FEHB benefits, trying to

or obtaining service or coverage for yourself or for someone else who is not eligible for coverage, or enrolling in the Plan

when you are no longer eligible.

•If your enrollment continues after you are no longer eligible for coverage (i.e. you have separated from Federal service)

and premiums are not paid, you will be responsible for all benefits paid during the period in which premiums were not

paid. You may be billed for services received directly by your provider. 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.

•Take a relative or friend with you to help you ask questions and understand answers.

4 2013 Coventry Health Plan of Florida Introduction/Plain Language/Advisory

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 drug allergies you have.

•Ask about any risks or side effects of the medication and what to avoid while taking it. Be sure to write down what your

doctor or pharmacist says.

•Make sure your medicine is what the doctor ordered. Ask the pharmacist about your medicine if it looks different than you

expected.

•Read the label and patient package insert when you get your medicine, including all warnings and instructions.

•Know how to use your medicine. Especially note the times and conditions when your medicine should and should not be

taken.

•Contact your doctor or pharmacist if you have any questions.

3. Get the results of any test or procedure.

•Ask when and how you will get the results of tests or procedures.

•Don’t assume the results are fine if you do not get them when expected, be it in person, by phone, or by mail.

•Call your doctor and ask for your results.

•Ask what the results mean for your care.

4. Talk to your doctor about which hospital is best for your health needs.

•Ask your doctor about which hospital has the best care and results for your condition if you have more than one hospital to

choose from to get the health care you need.

•Be sure you understand the instructions you get about follow-up care when you leave the hospital.

5. Make sure you understand what will happen if you need surgery.

•Make sure you, your doctor, and your surgeon all agree on exactly what will be done during the operation.

•Ask your doctor, “Who will manage my care when I am in the hospital?”

•Ask your surgeon:

- "Exactly what will you be doing?"

- "About how long will it take?"

- "What will happen after surgery?"

- "How can I expect to feel during recovery?"

•Tell the surgeon, anesthesiologist, and nurses about any allergies, bad reactions to anesthesia, and any medications you are

taking.

5 2013 Coventry Health Plan of Florida Introduction/Plain Language/Advisory

Patient Safety Links

•www.ahrq.gov/path/beactive.htm. The Agency for Healthcare Research and Quality makes available a wide-ranging list of

topics not only to inform consumers about patient safety but to help choose quality health care providers and improve the

quality of care you receive.

•www.npsf.org. The National Patient Safety Foundation has information on how to ensure safer health care for you and

your family.

•www.talkaboutrx.org. The National Council on Patient Information and Education is dedicated to improving

communication about the safe, appropriate use of medicines.

•www.leapfroggroup.org. The Leapfrog Group is active in promoting safe practices in hospital care.

•www.ahqa.org. The American Health Quality Association represents organizations and health care professionals working

to improve patient safety.

Never Events

You will not be billed for inpatient services related to treatment of specific hospital acquired conditions or for inpatient

services needed to correct Never Events, if you use Coventry Health Plan of Florida, Inc. preferred providers. This policy

helps to protect you from preventable medical errors and improve the quality of care you receive.

When you enter the hospital for treatment 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, severe bedsores and fractures; and reduce medical errors that should never happen called “Never Events.”

When a Never Event occurs, neither your FEHB plan nor you will incur costs to correct the medical error.

6 2013 Coventry Health Plan of Florida Introduction/Plain Language/Advisory

FEHB Facts

Coverage information

We will not refuse to cover the treatment of a condition you had before you enrolled in

this Plan solely because you had the condition before you enrolled.

• No pre-existing

condition limitation

See www.opm.gov/insure/health for enrollment information as well as:

• Information on the FEHB Program and plans available to you

• A health plan comparison tool

• A list of agencies who participate in Employee Express

• A link to Employee Express

• Information on and links to other electronic enrollment systems

Also, your employing or retirement office can answer your questions, and give you a

Guide to Federal Benefits,

brochures for other plans, and other materials you need to

make an informed decision about your FEHB coverage. These materials tell you:

• When you may change your enrollment;

• How you can cover your family members;

• What happens when you transfer to another Federal agency, go on leave without pay,

enter military service, or retire;

• When your enrollment ends

• When the next open season for enrollment begins.

We don’t determine who is eligible for coverage and, in most cases, cannot change your

enrollment status without information from your employing or retirement office. For

information on your premium deductions, you must also contact your employing or

retirement office.

• Where you can get

information about

enrolling in the FEHB

Program

Self Only coverage is for you alone. Self and Family coverage is for you, your spouse, and

your dependent children, including any foster children your employing or retirement

office authorizes coverage for. Under certain circumstances, you may also continue

coverage for a disabled child 26 years of age or older who is incapable of self-support.

If you have a qualifying life event (QLE) – such as marriage, divorce, or the birth of a

child – outside of the Federal Benefits Open Season, you may be eligible to enroll in the

FEHB Program, change your enrollment, or cancel coverage. For a complete list of QLEs,

visit the FEHB website at www.opm.gov/insure/lifeevents. If you need assistance, please

contact your employing agency, personnel/payroll office, or retirement office.

If you have a Self Only enrollment, you may change to a Self and Family enrollment if

you marry , give birth, or add a child to your family. You may change your enrollment 31

days before to 60 days after that event. The Self and Family enrollment begins on the first

day of the pay period in which the child is born or becomes an eligible family member.

When you change to Self and Family because you marry, the change is effective on the

first day of the pay period that begins after your employing office receives your

enrollment form; benefits will not be available to your spouse until you marry.

Your employing or retirement office will not notify you when a family member is no

longer eligible to receive benefits, nor will we. Please tell us immediately of changes in

family member status, including your marriage, divorce, annulment or when your child

reaches age 26.

• Types of coverage

available for you and

your family

7 2013 Coventry Health Plan of Florida FEHB Facts

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 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 OLEs, visit

the FEHB website at www.opm.gov/insure/lifeevents. If you need assistance, please

contact your employing agency, 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.

Children Coverage

Natural, adopted children, and stepchildren Natural, adopted children and stepchildren

are covered until their 26th birthday.

Foster Children Foster children are eligible for coverage

until their 26

birthday if you provide

documentation of your regular and

substantial support of the child and sign a

certification stating that your foster child

meets all the requirements. Contact your

human resources office or retirement system

for additional information.

Children Incapable of Self-Support Children who are incapable of self-support

because of a mental or physical disability

that began before age 26 are eligible to

continue coverage. Contact your human

resources office or retirement system for

additional information.

Married Children Married children (but NOT their spouses or

their own children) are covered until their

birthday.

Children with or eligible for employer-

provided health insurance

Children who are eligible for oe have their

own employer-provided health insurance are

covered until their 26

birthday.

You can find additional information at www.opm.gov/insure.

• Family member

coverage

OPM has implemented the Federal Employees Health Benefits Children’s Equity Act of

2000. This law mandates that you be enrolled for Self and Family coverage in the FEHB

Program, if you are an employee subject to a court or administrative order requiring you

to provide health benefits for your child(ren).

If this law applies to you, you must enroll for Self and Family coverage in a health plan

that provides full benefits in the area where your children live or provide documentation

to your employing office that you have obtained other health benefits coverage for your

children. If you do not do so, your employing office will enroll you involuntarily as

follows:

• If you have no FEHB coverage, your employing office will enroll you for Self and

Family coverage in the Blue Cross and Blue Shield Service Benefit Plan’s Basic

Option;

• If you have a Self Only enrollment in a fee-for-service plan or in an HMO that serves

the area where your children live, your employing office will change your enrollment

to Self and Family in the same option of the same plan; or

• Children’s Equity Act

8 2013 Coventry Health Plan of Florida FEHB Facts

• 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 2013 benefits of your old plan or

option. However, if your old plan left the FEHB Program at the end of the year, you are

covered under that plan’s 2012 benefits until the effective date of your coverage with your

new plan. Annuitants’ coverage and premiums begin on January 1. If you joined at any

other time during the year, your employing office will tell you the effective date of

coverage.

If your enrollment continues after you are no longer eligible for coverage (i.e. you have

separated from Federal service) and premiums are not paid, you will be responsible for all

benefits paid during the period in which premiums were not paid. You may be billed for

services received directly from your provider. You may be prosecuted for fraud for

knowingly using health insurance benefits for which you have not paid premiums. It is

your responsibility to know when you or a family member are no longer eligible to use

your health insurance coverage.

• When benefits and

premiums start

When you retire, you can usually stay in the FEHB Program. Generally, you must have

been enrolled in the FEHB Program for the last five years of your Federal service. If you

do not meet this requirement, you may be eligible for other forms of coverage, such as

Temporary Continuation of Coverage (TCC).

• When you retire

When you lose benefits

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

• Your enrollment ends, unless you cancel your enrollment, or

• You are a family member no longer eligible for coverage.

Any person covered under the 31 day extension of coverage who is confined in a hospital

or other institution for care or treatment on the 31st day of the temporary extension is

entitiled to continuation of the benefits of the Plan during the continuance of the

confinement but not beyond the 60th day after the end of the 31 day temporary extension.

You may be eligible for spouse equity coverage or Temporary Continuation of Coverage

(TCC), or a conversion policy (a non-FEHB individual policy.)

• When FEHB coverage

ends

9 2013 Coventry Health Plan of Florida FEHB Facts

If you are divorced from a Federal employee or annuitant, you may not continue to get

benefits under your former spouse’s enrollment. This is the case even when the court has

ordered your former spouse to provide health coverage to you. However, you may be

eligible for your own FEHB coverage under either the spouse equity law or Temporary

Continuation of Coverage (TCC). If you are recently divorced or are anticipating a

divorce, contact your ex-spouse’s employing or retirement office to get RI 70-5, the

Guide

To Federal Benefits,

or other information about your coverage choices. You can also

download the guide from OPM’s Web site, www.opm.gov/insure.

• Upon divorce

If you leave Federal service, or if you lose coverage because you no longer qualify as a

family member, you may be eligible for Temporary Continuation of Coverage (TCC). For

example, you can receive TCC if you are not able to continue your FEHB enrollment after

you retire, if you lose your Federal job, if you are a covered dependent child and you turn

26, etc.

You may not elect TCC if you are fired from your Federal job due to gross misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC, and the RI 70-5, the

Guide to

Federal Benefits,

from your employing or retirement office or from www.opm.gov/insure.

It explains what you have to do to enroll.

• Temporary

Continuation of

Coverage (TCC)

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

• Your coverage under TCC or the spouse equity law ends (If you canceled your

coverage or did not pay your premium, you cannot convert);

• You decided not to receive coverage under TCC or the spouse equity law; or

• You are not eligible for coverage under TCC or the spouse equity law.

If you leave Federal service, your employing office will notify you of your right to

convert. You must apply in writing to us within 31 days after you receive this notice.

However, if you are a family member who is losing coverage, the employing or retirement

office will not notify you. You must apply in writing to us within 31 days after you are no

longer eligible for coverage.

Your benefits and rates will differ from those under the FEHB Program; however, you will

not have to answer questions about your health, and we will not impose a waiting period

or limit your coverage due to pre-existing conditions.

• Converting to

individual coverage

The Health Insurance Portability and Accountability Act of 1996 (HIPAA) is a Federal

law that offers limited Federal protections for health coverage availability and continuity

to people who lose employer group coverage. If you leave the FEHB Program, we will

give you a Certificate of Group Health Plan Coverage that indicates how long you have

been enrolled with us. You can use this certificate when getting health insurance or other

health care coverage. Your new plan must reduce or eliminate waiting periods, limitations,

or exclusions for health related conditions based on the information in the certificate, as

long as you enroll within 63 days of losing coverage under this Plan. If you have been

enrolled with us for less than 12 months, but were previously enrolled in other FEHB

plans, you may also request a certificate from those plans.

For more information, get OPM pamphlet RI 79-27,

Temporary Continuation of Coverage

(TCC) under the FEHB Program

. See also the FEHB Web site at www.opm.gov/insure/

health; refer to the “TCC and HIPAA” frequently asked questions. These highlight HIPAA

rules, such as the requirement that Federal employees must exhaust any TCC eligibility as

one condition for guaranteed access to individual health coverage under HIPAA, and

information about Federal and State agencies you can contact for more information.

• Getting a Certificate

of Group Health Plan

Coverage

10 2013 Coventry Health Plan of Florida FEHB Facts

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 a 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 you 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 a negotiated payment from us, and you will only be responsible for your copayments or coinsurance.

Preventive care services

Preventive care services are generally covered with no cost-sharing and are not subject to copayments, deductibles or annual

limits when received from a network provider.

Annual deductible

The annual deductible must be met before Plan benefits are paid for care other than preventive care services.

Catastrophic protection

We protect you against catastrophic out-of-pocket expenses for covered services. Your annual out-of-pocket expenses for

covered services, including deductibles and copayments, cannot exceed $1,500 for self only enrollment, or $3,000 family

coverage, under the High Option or $2,500 for self only enrollment, or $5,000 for family coverage, under the Standard

Option.

11 2013 Coventry Health Plan of Florida Section 1

General features of our High Deductible Health Plan (HDHP)

HDHPs have higher annual deductibles and annual out-of-pocket maximum limits than other types of FEHB plans. FEHB

Program HDHPs also offer health savings accounts or health reimbursement arrangements. Please see below for more

information about these savings features.

Preventive care services

Preventive care services are generally paid as first dollar coverage or after a small deductible or copayment. First dollar

coverage may be limited to a maximum dollar amount each year.

Annual deductible

The annual deductible must be met before Plan benefits are paid for care other than preventive care services.

Health Savings Account (HSA)

You are eligible for an HSA if you are enrolled in an HDHP, not covered by any other health plan that is not an HDHP

(including a spouse’s health plan, but does not include specific injury insurance and accident, disability, dental care, vision

care, or long-term coverage), not enrolled in Medicare, not received VA benefits within the last three months, not covered by

your own or your spouse’s flexible spending account (FSA), and are not claimed as a dependent on someone else’s tax return.

•You may use the money in your HSA to pay all or a portion of the annual deductible, copayments, coinsurance, or other

out-of-pocket costs that meet the IRS definition of a qualified medical expense.

•Distributions from your HSA are tax-free for qualified medical expenses for you, your spouse, and your dependents, even

if they are not covered by a HDHP.

•You may withdraw money from your HSA for items other than qualified medical expenses, but it will be subject to income

tax and, if you are under 65 years old, an additional 20% penalty tax on the amount withdrawn.

•For each month that you are enrolled in an HDHP and eligible for an HSA, the HDHP will pass through (contribute) a

portion of the health plan premium to your HSA. In addition, you (the account holder) may contribute your own money to

your HSA up to an allowable amount determined by IRS rules. Your HSA dollars earn tax-free interest.

•You may allow the contributions in your HSA to grow over time, like a savings account. The HSA is portable – you may

take the HSA with you if you leave the Federal government or switch to another plan.

Health Reimbursement Arrangement (HRA)

If you are not eligible for an HSA, or become ineligible to continue an HSA, you are eligible for a Health Reimbursement

Arrangement (HRA). Although an HRA is similar to an HSA, there are major differences.

•An HRA does not earn interest.

•An HRA is not portable if you leave the Federal government or switch to another plan.

Catastrophic protection

We protect you against catastrophic out-of-pocket expenses for covered services. Your annual out-of-pocket expenses for

covered services, including deductibles and copayments, cannot exceed $6,250 for self only enrollment, or $12,500 family

coverage.

12 2013 Coventry Health Plan of Florida Section 1

Health education resources and accounts management tools

Your rights

OPM requires that all FEHB Plans provide certain information to their FEHB members. You may get information about us,

our networks, and our providers. OPM’s FEHB Website (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 Plan of Florida, Inc. is a for-profit entity and has been operational since 1984.

•Coventry Health Plan of Florida received a three-year accreditation from the Accreditation Association for Ambulatory

Health Care, Inc.

•Coventry Health Plan of Florida, Inc., is licensed by the Florida Financial Services Commission.

If you want more information about us, call 1-866-575-1882, or write to Coventry Health Care of Florida, Inc., 1340

Concord Terrace, Sunrise, Florida 33323. You may also contact us by fax at 954-846-8873 or visit our website feds.

chcflorida.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 physicians 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

covers South Florida – Broward, Miami-Dade, Martin, Palm Beach and St. Lucie counties.

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. Reciprocity arrangements do not exist in any other

Coventry Health Plan of Florida, Inc. networks. If you or a family member moves, you do not have to wait until Open Season

to change plans. Contact your employing or retirement office.

13 2013 Coventry Health Plan of Florida Section 1

Section 2. Changes for 2013

Do not rely only on these change descriptions; this Section is not an official statement of benefits. For that, go to Section 5

Benefits. Also, we edited and clarified language throughout the brochure; any language change not shown here is a

clarification that does not change benefits.

Program wide changes

•Removed annual limits on essential health benefits as described in section 1302 of the Affordable Care Act.

•Plans must provide coverage for routine patient costs for items and services furnished in connection with participation in

an approved clinical trial.

•Coverage with no cost sharing for additional preventive care screenings for women provided in comprehensive guidelines

adopted by the Health Resources and Services Administration (HRSA).

Changes to High Option only

•Your share of non-postal premium will increase for Self Only and Family. See page 120.

•Applied Behavioral Analysis (ABA) services for the treatment of Autism Spectrum Disorder are now covered subject to a

$30 copay per visit.

Changes to Standard Option only

•Your share of non-postal premium will increase for Self Only and Family. See page 120.

•The inpatient hospital copayment is now $150 per day for the first 5 days after satisfaction of the $500 hospital deductible.

Previously, the benefit was $100 per day for the first 5 days.

•Outpatient diagnostic tests provided and billed by a hospital when performed at a Outpatient hospital has a $75 copay after

deductible and $500 deductible per visit. Previously, the copayment was $50 after the $500 deductible.

•Retail prescription drug benefit has expanded to 5 tiers from 4 tiers. Tier 1A covers select generic drugs subject to a $3

copayment per prescription. Copayments for the other tiers will remain at their current level.

•Applied Behavioral Analysis (ABA) services for the treatment of Autism Spectrum Disorder are now covered subject to a

$50 copay per visit.

Changes to High Deductible Health Plan (HDHP) Option only

•Your share of non-postal premium will increase for Self Only and Family. See page 120.

•Applied Behavioral Analysis (ABA) services for the treatment of Autism Spectrum Disorder are now covered. Members

cost sharing is as follows. At a hospital, member pays 20% of charges after the $2,500 calendar year deductible. At a

freestanding facility, member pays $25 per visit after the $2,500 calendar year deductible.

14 2013 Coventry Health Plan of Florida Section 2

Section 3. How you get care

We will send you an identification (ID) card when you enroll. You should carry your ID

card with you at all times. You must show it whenever you receive services from a Plan

provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use

your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment

confirmation letter (for annuitants), or your electronic enrollment system (such as

Employee Express) confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your

enrollment, or if you need replacement cards, call us at 1-866-575-1882 or write to us at

Coventry Health Care of Florida, Attn: Customer Service, 1340 Concord Terrace,

Sunrise, Florida 33323. You may also request replacement cards through our website at

feds.chcflorida.com.

Identification cards

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 network.

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 Web site.

• 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 Web site.

• Plan facilities

It depends on the type of care you need. First, you and each family member must choose a

primary care physician. This decision is important since your primary care physician

provides or arranges for most of your health care.

What you must do to get

covered care

If you want to change primary care physicians or if your primary care physician leaves the

Plan, call us. We will help you select a new one.

• Primary care

Here are some other things you should know about specialty care:

• If you need to see a specialist frequently because of a chronic, complex, or serious

medical condition, your primary care physician will develop a treatment plan that

allows you to see your specialist for a certain number of visits without additional

referrals. Your primary care physician will use our criteria when creating your

treatment plan (the physician may have to get an authorization or approval

beforehand).

• If you are seeing a specialist when you enroll in our Plan, talk to your primary care

physician. Your primary care physician will decide what treatment you need. If he or

she decides to refer you to a specialist, ask if you can see your current specialist. If

your current specialist does not participate with us, you must receive treatment from a

specialist who does. Generally, we will not pay for you to see a specialist who does

not participate with our Plan.

• If you are seeing a specialist and your specialist leaves the Plan, call your primary care

physician, who will arrange for you to see another specialist. You may receive services

from your current specialist until we can make arrangements for you to see someone

else.

• Specialty care

15 2013 Coventry Health Plan of Florida Section 3

• If you have a chronic and disabling condition and lose access to your specialist

because we:

- terminate our contract with your specialist for other than cause; or

- drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll

in another FEHB program Plan

- 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.

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

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 1-866-575-1882. 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

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 specialists 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

services

Your primary care physician has authority to refer you for most services. For certain

services, however, your physician must obtain prior approval from us. Before giving

approval, we consider if the service is covered, medically necessary, and follows generally

accepted medical practice. You must obtain prior authorization for:

• Air ambulance (non-emergency)

• Ambulance Transport (non-emergency)

• Automatic Implantable Cardioverter Defibrillator (A.I.C.D.)

• Blepharoplasty

• Bone Growth Stimulators

• Breast Surgery for Benign Condition

• Clinitron Bed

• Other services

16 2013 Coventry Health Plan of Florida Section 3

• Cosmetic Surgery

• CTA/CCTA/CT

• Customized Wheelchairs

• DME

• Echo Stress

• Enhanced External Counter Pulsation

• Experimental/Investigational Services

• Extracorporeal Shock Wave Therapy/Orthotripsy

• Gastric Bypass/Banding

• Home Health Services

• Home Vents

• Hospice Care

• Hospital Admission

• Hospital Outpatient Services (all, includes diagnostic testing)

• Hyperbaric Treatments

• Infertility Assessment/Treatment

• Infusion/Home/Office Drug-Replacement

• Laparoscopic Hysterectomy

• Liquid Oxygen

• Manipulation Under Anesthesia

• Maternal fetal medicine

• MRA/MRI

• Neuropsychology

• Non-participating providers

• Nuclear Cardiology

• Nuclear Medicine

• Oral surgery

• Pain Management

• Panniculectomy/Abdominoplasty

• PET Scans

• Power Mobility Devices (power wheelchair and scooters)

• Prosthetics/Braces/Orthotics

• Rehabilitation Facility Inpatient Admission

• Rehabilitation Therapies (PT, ST, OT)

• Removal of Keloid/Lipomas

• Reproductive Endocrinology

• Rhinoplasty/Septoplasty

• Sclerotherapy for Vericose Veins

• Skilled Nursing Facility Admission

• Sleep Studies

• Transplant Evaluations/Transplants

• Ultrasound, Pregnant Uterus, Transvaginal (76817)

• Uvulopalatopharyngoplasty

17 2013 Coventry Health Plan of Florida Section 3

• Vent/Sub-acute, Long Term Care Admission

• Wound care centers (non-emergency)

• Wound Vacs

Clinical information will be required to substantiate request. The above list is subject to

change.

First, your physician, your hospital, you, or your representative, must call us at

800-528-2705 or 954-858-3437 before admission or services requiring prior authorization

are rendered.

Next, provide the following information:

• enrollee’s name and Plan identification number;

• patient’s name, birth date, identification number and phone number;

• reason for hospitalization, proposed treatment, or surgery;

• name and phone number of admitting physician;

• name of hospital or facility; and

• number of planned days of confinement.

• How to request

precertification for an

admission or get prior

authorization for

Other services

For non-urgent care claims, we will then tell the physician and/or hospital the number of

approved inpatient days, or the care that we approve for other services that must have

prior authorization. We will make our decision within 15 days of receipt of the pre-

service claim. If matters beyond our control require an extension of time, we may take up

to an additional 15 days for review and we will notify you of the need for an extension of

time before the end of the original 15 day period. Our notice will include the

circumstances underlying the request for the extension and the date when a decision is

expected.

If we need an extension because we have not received necessary information from you,

our notice will describe the specific information required and we will allow you up to 60

days from the receipt of the notice to provide the information.

• Non-urgent care

claims

If you have an urgent care claim (i.e., when waiting for the regular time limit for your

medical care or treatment could seriously jeopardize your life, health, or ability to regain

maximum function, or in the opinion of a physician with knowledge of your medical

condition, would subject you to severe pain that cannot be adequately managed without

this care or treatment), we will expedite our review and notify you of our decision within

72 hours. If you request that we review your claim as an urgent care claim, 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) the end of the time

frame, whichever is earlier.

We may provide our decision orally within these time frames, but we will follow up with

written or electronic notification within three days of oral notification.

• Urgent care claims

18 2013 Coventry Health Plan of Florida Section 3

You may request that your urgent care claim on appeal be reviewed simultaneously by us

and OPM. Please let us know that you would like a simultaneous review of your urgent

care claim by OPM either in writing at the time you appeal our initial decision, or by

calling us at 866-575-1882. 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, then call us at

866-575-1882. If it is determined that your claim is an urgent care claim, we will hasten

our review (if we have not yet responded to your claim).

If you have an emergency admission due to a condition that you reasonably believe puts

your life in danger or could cause serious damage to bodily function, you, your

representative, the physician, or the hospital must telephone us within two business days

following the day of the emergency admission, even if you have been discharged from the

hospital.

• Emergency inpatient

admission

If you request an extension of an ongoing course of treatment at least 24 hours prior to the

expiration of the approved time period and this is also an urgent care claim, then we will

make a decision within 24 hours after we receive the claim.

• If your treatment

needs to be extended

If prior approval is not given for services provided by a non-network facility/provider, the

Healthplan shall have no liability or obligation whatsoever, on account of services or

benefits sought or received by any member from any non-network physician, health

professional, hospital or other health care facility, or other person, institution or

organization.

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 receive it within 60 days of our

request. We will then decide within 30 more days.

If we do not receive the information within 60 days we will decide within 30 days of the

date of the information was due. We will base our decision on the information we already

have. We will write to you with our decision.

Write to you and maintain our denial.

• To reconsider a non-

urgent care claim

In the case of an appeal of a pre-service urgent care claim, within 6 months of our initial

decision, you may ask us in writing to reconsider our initial decision. Follow Step 1 of

the disputed claims process detailed in Section 8 of this brochure.

• To reconsider an

urgent care claim

19 2013 Coventry Health Plan of Florida Section 3

Subject to a request for additional information, we will notify you of our decision within

72 hours after receipt of your reconsideration request. We will hasten the review process,

which allows oral or written requests for appeals and the exchange of information by

telephone, electronic mail, facsimile, or other expeditious methods.

After we reconsider your pre-service claim, if you do not agree with our decision, you

may ask OPM to review it by following Step 3 of the disputed claims process detailed in

Section 8 of this brochure.

• To file an appeal with

OPM

20 2013 Coventry Health Plan of Florida Section 3

Section 4. Your cost 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 certain services.

Example: under the high option, when you see your primary care physician you pay a

copayment of $15 per office visit and when you go in the hospital, you pay $150 per

admission for the first 3 days.

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 any deductible.

• The hospital deductible is $250 covered per person under High Option and $500 per

covered person under Standard Option.

• The hospital deductible is $2,500 covered per person and $5,000 per family

enrollment under High Deductible Health Plan.

Note: If you change plans during open season, you do not have to start a new deductible

under your old plan between January 1

and the effective date of your new plan. If you

change plans at another time during the year, you must begin a new deductible under your

new plan.

If you change options in this Plan during the year, we will credit the amount of covered

expenses already applied toward the deductible of your old option to the deductible of

your new option.

Deductible

Coinsurance is the percentage of our allowance that you must pay for your care.

Coinsurance does not begin until you have met your calendar year deductible.

Example: In our Plan, you pay 50% of our allowance for infertility services and durable

medical equipment.

Coinsurance

After your High Option (copayments and annual hospital deductible) total $1,500 per

person or $3,000 per family or, $2,500 per person or $5,000 per family enrollment on the

Standard Option in any calendar year, you do not have to pay any more for covered

services. However, prescription drugs and vision care copayments do not count toward

your catastrophic protection out-of-pocket maximum, and you must continue to pay

copayments for these services.

When you use network providers, your annual maximum for out-of-pocket expenses for

the High Deductible Health Plan (deductibles, coinsurance and copayments) for covered

services is limited to $5,000 per person or $10,000 per family enrollment. However,

prescription drugs and vision care copayments do not count toward your out-of-pocket

maximum and you must continue to pay these expenses once you reach your out-of-

pocket maximum (such as expenses in excess of the Plan's allowable amount or benefit

maximum).

Be sure to keep accurate records of your copayments since you are responsible for

informing us when you reach the maximum.

Your catastrophic

protection out-of-pocket

maximum

21 2013 Coventry Health Plan of Florida Section 4

Facilities of the Department 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

22 2013 Coventry Health Plan of Florida Section 4

High and Standard Option Benefits

See page 14 for how our benefits changed this year. Pages 117 and 118 are a benefits summary of each option. Make sure

that you review the benefits that are available under the option in which you are enrolled.

Section 5. High and Standard Option Benefits Overview ..........................................................................................................25

Section 5(a). Medical services and supplies provided by physicians and other health care professionals .................................26

Diagnostic and treatment services .....................................................................................................................................26

Lab, X-ray and other diagnostic tests ................................................................................................................................26

Preventive care, adult ........................................................................................................................................................27

Preventive care, children ...................................................................................................................................................28

Maternity care ...................................................................................................................................................................28

Family planning ................................................................................................................................................................29

Infertility services .............................................................................................................................................................29

Allergy care .......................................................................................................................................................................30

Treatment therapies ...........................................................................................................................................................30

Physical and occupational therapies .................................................................................................................................31

Hearing services (testing, treatment, and supplies) ...........................................................................................................31

Vision services (testing, treatment, and supplies) .............................................................................................................32

Foot care ............................................................................................................................................................................32

Orthopedic and prosthetic devices ....................................................................................................................................33

Durable medical equipment (DME) ..................................................................................................................................33

Home health services ........................................................................................................................................................34

Chiropractic .......................................................................................................................................................................35

Alternative treatments .......................................................................................................................................................35

Educational classes and programs .....................................................................................................................................35

Section 5(b). Surgical and anesthesia services provided by physicians and other health care professionals .............................36

Surgical procedures ...........................................................................................................................................................36

Reconstructive surgery ......................................................................................................................................................37

Oral and maxillofacial surgery ..........................................................................................................................................38

Organ/tissue transplants ....................................................................................................................................................39

Anesthesia .........................................................................................................................................................................44

Section 5(c). Services provided by a hospital or other facility, and ambulance services ...........................................................45

Inpatient hospital ...............................................................................................................................................................45

Outpatient hospital or ambulatory surgical center ............................................................................................................46

Extended care benefits/Skilled nursing care facility benefits ...........................................................................................46

Hospice care ......................................................................................................................................................................47

Ambulance ........................................................................................................................................................................47

Section 5(d). Emergency services/accidents ...............................................................................................................................48

Emergency within our service area ...................................................................................................................................49

Emergency outside our service area ..................................................................................................................................49

Ambulance ........................................................................................................................................................................49

Section 5(e). Mental health and substance abuse benefits ..........................................................................................................50

Professional services .........................................................................................................................................................50

Diagnostics ........................................................................................................................................................................51

Inpatient hospital or other covered facility .......................................................................................................................51

Not covered .......................................................................................................................................................................51

Preauthorization ................................................................................................................................................................51

Limitation ..........................................................................................................................................................................51

23 2013 Coventry Health Plan of Florida

Section 5(f). Prescription drug benefits ......................................................................................................................................52

Covered medications and supplies ....................................................................................................................................53

Section 5(g). Dental benefits .......................................................................................................................................................56

Accidental injury benefit ...................................................................................................................................................56

Section 5(h). Special features ......................................................................................................................................................57

Flexible benefits option .....................................................................................................................................................57

Services for deaf and hearing impaired .............................................................................................................................57

High risk pregnancies ........................................................................................................................................................57

Centers of excellence for transplants ................................................................................................................................57

Travel benefit/services overseas .......................................................................................................................................57

Summary of benefits for the High Option of Coventry Health Plan of Florida 2013 ...............................................................117

Summary of benefits for the Standard Option of Coventry Health Plan of Florida 2013 .........................................................118

24 2013 Coventry Health Plan of Florida

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,

Each option offers unique features.

•High Option The High Option has lower copayments and higher premiums.

•Standard Option The Standard Option has higher copayments and lower premiums.

25 2013 Coventry Health Plan of Florida Section 5

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.

•HMO Plans are Open Access.

•Each member must satisfy a hospital deductible of $250 if on the High Option or $500 if on the

Standard Option for all services billed by a hospital, except emergency services. Facility

copayments also apply to surgical services that appear in this section but are performed in an

ambulatory surgical center or in the outpatient department of a hospital.

•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

Note: The hospital deductible applies to all inpatient and outpatient services at a hospital.

We say "(no deductible)" when it does not apply.

Diagnostic and treatment services High Option Standard Option

Professional services of physicians

• In physician’s office

$15 per office visit to your

primary care physician or $30

per office visit to a specialist

$20 per office visit to your

primary care physician or $50

per office visit to a specialist

Professional services of physicians

• In an urgent care center $40 per office visit $50 per office visit

• During a hospital stay Nothing Nothing

• In a skilled nursing facility Nothing Nothing

• Office medical consultations $30 per office visit $50 per office visit

• Second surgical opinion Nothing if performed by a plan

physician or 40% of UCR if

performed by a non-plan

physician

$20 if performed by a primary

care physician, $50 if

performed by a specialist or

40% of UCR if performed by a

non-plan physician

At home $15 per visit from your primary

care physician or $30 per visit

from a specialist

$20 per visit from your primary

care physician or $50 per visit

from a specialist

Lab, X-ray and other diagnostic tests High Option Standard Option

Tests, such as:

• Blood tests

• Urinalysis

• Non-routine Pap tests

• Pathology

$15 per office visit to your

primary care physician or $30

per office visit to a specialist

Nothing when performed at a

participating freestanding

laboratory or radiology center

Note: These services are

subject to the annual deductible

when performed in a hospital.

See Section 5(c).

$20 per office visit to your

primary care physician or $50

per office visit to a specialist

Nothing when performed at a

participating freestanding

laboratory or radiology center

Note: These services are

subject to the annual deductible

when performed in a hospital.

See Section 5(c).

Lab, X-ray and other diagnostic tests - continued on next page

26 2013 Coventry Health Plan of Florida Section 5(a)

High and Standard Option

Benefit Description You pay

Lab, X-ray and other diagnostic tests (cont.) High Option Standard Option

• X-rays

• Non-routine Mammograms

• Electrocardiogram and EEG

• CAT Scans/MRI

• Ultrasound

Nothing when performed at a

participating freestanding

labratory or radiology center

Note: These services are

subject to the annual deductible

when performed in a hospital.

See Section 5(c).

$100 if performed at a

participating freestanding

laboratory or radiology center

Note: These services are

subject to the annual deductible

when performed in a hospital.

See Section 5(c).

Preventive care, adult High Option Standard Option

Routine physical every year which includes

Routine screenings, such as:

• Total Blood Cholesterol

• Colorectal Cancer Screening , including

• Fecal occult blood test

• Sigmoidoscopy, screening – every five years

starting at age 50

• Double contrast barium enema – every five

years starting at age 50

• Colonoscopy screening – every ten years

starting at age 50

Nothing Nothing

• Routine Prostate Specific Antigen (PSA) test - one

annually for men 40 and older

Nothing Nothing

Well woman - one annually; including, but not

limited to:

• Routine pap test.

• Human papillomavirus testing for women age 30

and up once every three years.

• Counseling for sexually transmitted infections on

an annual basis.

• Counseling and screening for human immune-

deficiency virus on an annual basis.

• Contraceptive methods and counseling.

• Screenings and counseling for interpersonal and

domestic violence.

Nothing Nothing

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 calendar year

• At age 65 and older, one every two consecutive

calendar years

Nothing Nothing

Adult routine immunizations endorsed by the Centers

for Disease Control and Prevention (CDC):

Nothing Nothing

Preventive care, adult - continued on next page

27 2013 Coventry Health Plan of Florida Section 5(a)

High and Standard Option

Benefit Description You pay

Preventive care, adult (cont.) High Option Standard Option

Not covered:

•

Physical exams and immunizations required for

obtaining or continuing employment or insurance,

attending schools or camp, or travel.

All Charges All Charges

Preventive care, children High Option Standard Option

Professional services, such as:

• Well-child care charges for routine examinations,

immunizations and care (up to age 26)

• Childhood immunizations recommended by the

American Academy of Pediatrics

Examinations, such as:

• Eye exams through age 17 to determine the need

for vision correction

• Hearing exams through age 17 to determine the

need for hearing correction

Nothing Nothing

Not covered:

•

Physical exams, required for obtaining or

continuing employment or insurance, attending

schools or camp, or travel.

•

Immunizations, boosters, and medications for

travel

All charges All charges

Maternity care High Option Standard Option

Complete maternity (obstetrical) care, such as:

• Prenatal care

• Delivery

• Postnatal care

Nothing for prenatal care or the

first postpartum care visit; $30

per office visit for all

postpartum care visits

thereafter.

Nothing for inpatient

professional delivery services

One time $50 copay for

prenatal care and the first

postpartum care visit; $50 per

office visit for all postpartum

care visits thereafter.

Nothing for inpatient

professional delivery services

• Screening for gestational diabetes for pregnant

women between 24-28 weeks gestation or first

prenatal visit for women at a high risk.

Nothing Nothing

• Breastfeeding support, supplies and counseling for

each birth

Nothing Nothing

Note: Here are some things to keep in mind:

• You do not need to precertify your normal delivery;

see page 16 for other circumstances, such as

extended stays for you on 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.

Maternity care - continued on next page

28 2013 Coventry Health Plan of Florida Section 5(a)

High and Standard Option

Benefit Description You pay

Maternity care (cont.) High Option Standard Option

• 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. Surgical benefits, not maternity

benefits, apply to circumcision.

• We pay hospitalization and surgeon services for

non-maternity care the same as for illness and

injury.

Family planning High Option Standard Option

Contraceptive counseling on an annual basis Nothing Nothing

A range of voluntary family planning services,

limited to:

• Voluntary sterilization (See Surgical procedures

Section 5 (b)

• Surgically implanted contraceptives

• Injectable contraceptive drugs (such as Depo

provera)

• Intrauterine devices (IUDs)

• Diaphragms

Note: We cover oral contraceptives under the

presciption drug benefit.

Nothing Nothing

Not covered:

•

Reversal of voluntary surgical sterilization

•

Genetic counseling

All charges All charges

Infertility services High Option Standard Option

Diagnosis and treatment of infertility such as:

• Artificial insemination:

- Intravaginal insemination (IVI)

- Intracervical insemination (ICI)

- Intrauterine insemination (IUI)

• Fertility drugs

Note: We cover injectible fertility drugs under

medical benefits and oral fertility drugs under the

prescription drug benefit.

$15 per office visit to your

primary care physician or $30

per visit to a specialist

$20 per office visit to your

primary care physician or $50

per visit to a specialist

Infertility services - continued on next page

29 2013 Coventry Health Plan of Florida Section 5(a)

High and Standard Option

Benefit Description You pay

Infertility services (cont.) High Option Standard Option

Not covered:

Assisted reproductive technology (ART) procedures,

such as:

•

In vitro fertilization

•

Embryo transfer, gamate intra-fallopian transfer

(GIFT)

•

Zygote intra-fallopian transfer (ZIFT)

•

Services and supplies related to ART procedures

•

Drugs to treat infertility

•

Cost of donor sperm

•

Cost of donor egg

All charges All charges

Allergy care High Option Standard Option

• Testing and treatment

• Allergy injections

$15 per office visit to your

primary care physician or $30

per office visit to a specialist

$20 per office visit to your

primary care physician or $50

per office visit to a specialist

• Allergy serum Nothing Nothing

Not covered: Provocative food testing and 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 39.

• Respiratory and inhalation therapy

• Dialysis – hemodialysis and peritoneal dialysis

• Intravenous (IV)/Infusion Therapy – Home IV and

antibiotic therapy

• Applied Behavior Analysis (ABA) Therapy for

Autism Spectram Disorder

• Growth hormone therapy (GHT)

Note: Growth hormone is covered under the

prescription drug benefit.

Note: We only cover GHT when we preauthorize the

treatment. We will ask you to submit information that

establishes that the GHT is medically necessary. Ask

us to authorize GHT before you begin treatment. We

will only cover GHT services and related services and

supplies that we determine are medically necessary.

See

Other services under You need prior Plan

approval for certain services

on page 16.

$15 per office visit to your

primary care physician or $30

per office visit to a specialist

$20 per office visit to your

primary care physician or $50

per office visit to a specialist

Treatment therapies - continued on next page

30 2013 Coventry Health Plan of Florida Section 5(a)

High and Standard Option

Benefit Description You pay

Treatment therapies (cont.) High Option Standard Option

Not covered:

•

Chelation therapy

•

Any furniture, plumbing, electrical or other fixtures

to perform dialysis at home.

All Charges All Charges

Physical and occupational therapies High Option Standard Option

60 visits per calendar year; no less than 2 consecutive

months of therapy for each condition for each of the

following services:

• Qualified physical therapists

• Occupational therapists

Note: We only cover therapy to restore bodily

function when there has been a total or partial loss of

bodily function due to illness or injury.

Cardiac rehabilitation following a heart transplant,

bypass surgery or a myocardial infarction is provided

for up to 100 sessions.

$30 per office visit

Nothing per visit during

covered inpatient admission

Note: The annual deductible

and facility copayments apply

to services billed by a hospital.

$50 per office visit

Nothing per visit during

covered inpatient admission

Note: The annual deductible

and facility copayments apply

to services billed by a hospital.

Not covered:

•

Long-term rehabilitative therapy

•

Exercise programs

•

Pulmonary rehabilitation

All charges All charges

Speech therapy High Option Standard Option

60 visit per calendar year; no less than 2 consecutive

months of therapy for each condition.

$30 per office visit

Nothing per visit during

covered inpatient admission

Note: The annual deductible

and facility copayments apply

to services billed by a hospital.

$50 per office visit

Nothing per visit during

covered inpatient admission

Note: The annual deductible

and facility copayments apply

to services billed by a hospital.

Hearing services (testing, treatment, and

supplies)

High Option Standard Option

• For treatment related to illness or injury; including

evaluation and diagnostic hearing tests performed

by a 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.

Nothing Nothing

• External hearing aids

• 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.

Nothing Nothing

Hearing services (testing, treatment, and supplies) - continued on next page

31 2013 Coventry Health Plan of Florida Section 5(a)

High and Standard Option

Benefit Description You pay

Hearing services (testing, treatment, and

supplies) (cont.)

High Option Standard Option

Not covered:

Hearing services that are not shown as covered

All charges All charges

Vision services (testing, treatment, and

supplies)

High Option Standard Option

• Annual eye refractions, including written lens

prescription.

Note: See

Preventive care, children

for eye exams for

children.

$19 per office visit at a

participating optometrist or $30

per office visit to a specialist

$19 per office visit at a

participating optometrist or $50

per office visit to a specialist

• Frames (one pair of each calendar year from the

Coventry Health Care of Florida Standard

collection at a participating provider)

Nothing Nothing

• One pair of frames or contact lenses to correct an

impairment directly caused by accidental ocular

injury or intraocular surgery (such as for cataracts)

$30 per office visit to a

specialist

$50 per office visit to a

specialist

• Standard Select Plan Frames (preselected

collection)

Nothing Nothing

• Single vision lenses $20 $20

• Bifocal lenses $25 $25

• Trifocal lenses $30 $30

Contact Lenses

• Medically necessary contact lenses (evaluation and

fitting) in lieu of eyeglasses

Nothing Nothing

• Daily wear contact lenses (Bausch & Lomb,

Biomedics)

$10 $10

• Extended wear contact lenses (Bausch & Lomb) $15 $15

• Disposable lenses (2 boxes of all clear spherical

lens)

$48 $48

• All eyewear (including contact lenses) outside of

the Standard Select plan (preselected collection)

Retail cost minus 20% discount Retail cost minus 20% discount

Not covered:

•

Eye exercises and orthoptics

•

Radial keratotomy and other refractive surgery

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.

$15 per office visit to your

primary care physician or $30

per visit to a specialist

$20 per office visit to your

primary care physician or $50

per visit to a specialist

Not covered

•

Cutting, triming or removal of corns, calluses or

the free edge of toenails, and similar routine

treatment of conditions of the foot, except as stated

above

All Charges All Charges

Foot care - continued on next page

32 2013 Coventry Health Plan of Florida Section 5(a)

High and Standard Option

Benefit Description You pay

Foot care (cont.) High Option Standard Option

•

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

• External hearing aids

• Implanted hearing-related devices, such as bone

anchored hearing aids (BAHA) and cochlear

implants

• Internal prosthetic devices , such as artificial joints,

pacemakers, cochlear implants, and surgically

implanted breast implant following mastectomy.

Note: For information on the professional charges for

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.

Nothing Nothing

Not covered:

•

Orthopedic and corrective shoes, arch supports,

foot orthotics, heel pads and heel cups

•

Lumbosacral supports

•

Corsets, trusses, elastic stockings, suppor t h ose,

and other supportive devices

•

Prosthetic replacements provided less than 3 years

after the last one we covered

All Charges All Charges

Durable medical equipment (DME) High Option Standard Option

We cover rental or purchase of durable medical

equipment, at our option, including repair and

adjustment. Covered items include:

• Oxygen

• Dialysis equipment

• Hospital beds

• Wheelchairs

• Crutches

• Walkers

Nothing Nothing

Durable medical equipment (DME) - continued on next page

33 2013 Coventry Health Plan of Florida Section 5(a)

High and Standard Option

Benefit Description You pay

Durable medical equipment (DME) (cont.) High Option Standard Option

• Audible prescription reading devices

• Speech generating devices

• Blood glucose monitors

• Insulin pumps

Note: Call us at (866) 575-1882 as soon as your Plan

physician prescribes this equipment. We will arrange

with a health care provider to rent or sell you durable

medical equipment at discounted rates and will tell

you more about this service when you call.

Nothing Nothing

Not covered:

•

Motorized wheelchairs unless medically necessary

to meet the minimum functional requirements of

the member

•

More than one device for the same body part or

more than one piece of equipment that serves the

same function

•

Spare or alternate use devices

•

Adjust, repair or maintenance of devices which are

worn or damaged as a result of abuse

•

Replacement of lost devices

•

Exercise equipment and bicycles

•

Elevators and chair lifts, plus home and automobile

modifications

•

Air conditioners, humidifiers, dehumidifiers, air

purifiers, pillows, whirlpools, spas, jacuzzis, and

saunas

•

Any equipment that does not serve a medical

purpose

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.), or home health aide.

• Services include oxygen therapy, intravenous

therapy and medications.

Note: See Section 5(a) Diagnostic and Treatment

Services for the amount you pay for physician visits

in the home.

Nothing Nothing

Not covered:

•

Nursing care requested by, or for the convenience

of, the patient or the patient's family.

•

Home care primarily for personal assistance that

does not include a medical component and is not

diagnostic, therapeutic or rehabilitative.

All Charges All Charges

Home health services - continued on next page

34 2013 Coventry Health Plan of Florida Section 5(a)

High and Standard Option

Benefit Description You pay

Home health services (cont.) High Option Standard Option

•

Services primarily for hygiene, feeding, exercising,

moving the patient, homemaking, companionship

or giving oral medication.

All Charges All Charges

Chiropractic High Option Standard Option

• Manipulation of the spine and extremities

• Adjunctive procedures such as ultrasound,

electrical muscle stimulation, vibratory therapy,

and cold pack application

$30 per office visit $50 per office visit

Not covered: All services not deemed medically

necessary.

All charges All charges

Alternative treatments High Option Standard Option

Acupuncture - by a doctor of medicine or osteopathy

for:

• anesthesia

• pain relief

$30 per office visit $50 per office visit

Not covered:

•

Naturopathic services

•

Hypnotherapy

•

Biofeedback

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.

Nothing for two counseling

sessions for up to four quit

attempts per year.

Nothing for OTC and

prescription drugs approved by

the FDA to treat tobacco

dependence.

Nothing for two counseling

sessions for up to four quit

attempts per year.

Nothing for OTC and

prescription drugs approved by

the FDA to treat tobacco

dependence.

• Diabetes self management $30 per office visit $50 per office visit

• Childhood obesity education Nothing Nothing

35 2013 Coventry Health Plan of Florida 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.

•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 hospital deductible is: for the High Option $250 per person and for the Standard Option $500

per person. The hospital deductible applies to almost all benefits in this Section. We added "(No

deductible)" to show when the hospital deductible does not apply.

•The amounts listed below are for the charges billed by a physician or other health care professional

for your surgical care. We will also apply a facility copay to surgical services that appear in this

section but are performed in an ambulatory surgical center or in the outpatient department of a

hospital. Look in Section 5(c) for charges associated with the facility (i.e. hospital, surgical center,

etc.).

•YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME SURGICAL

PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure

which services require precertification and identify which surgeries require precertification.

Benefit Description You pay

Note: The hospital deductible applies to all inpatient and outpatient services at a hospital.

We say "(No deductible)" when it does not apply.

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 a surgeon

• Correction of amblyopia and strabismus

• Endoscopy procedures

• Biopsy procedures

• Removal of tumors and cysts

• Correction of congenital anomalies (see

Reconstructive surgery

)

• Surgical treatment of morbid obesity (bariatric

surgery)

• Insertion of internal prosthetic devices. See 5(a) -

Orthopedic and prosthetic devices

for device

coverage information

Note: Generally, we pay for internal prostheses

(devices) according to where the procedure is done.

For example, we pay Hospital benefits for pacemaker

and Surgery benefits for insertion of the pacemaker.

$15 per office visit to your

primary care physician or $30

per visit to a specialist

Nothing for the physician's

charge for surgery

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductible. The deductible

applies to all services billed by

a hospital.

$20 per office visit to your

primary care physician or $50

per visit to a specialist

Nothing for the physician's

charge for surgery

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductible. The deductible

applies to all services billed by

a hospital.

Surgical procedures - continued on next page

36 2013 Coventry Health Plan of Florida Section 5(b)

High and Standard Option

Benefit Description You pay

Surgical procedures (cont.) High Option Standard Option

• Voluntary sterilization (e.g., vasectomy) $200 copayment

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductible. The $250 annual

deductible applies to all

services billed by a hospital.

$200 copayment

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductible. The $500 annual

deductible applies to all

services billed by a hospital.

Treatment of burns $15 per office visit to your

primary care physician or $30

per visit to a specialist

Nothing for the physician's

charge for surgery

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductible. The deductible

applies to all services billed by

a hospital.

$20 per office visit to your

primary care physician or $50

per visit to a specialist

Nothing for the physician's

charge for surgery

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductible. The deductible

applies to all services billed by

a hospital.

Surgical treatment of morbid obesity (bariatric

surgery)

Note: you must satisfy all of the following criteria in

order for us to consider the surgery:

• Body mass Index (BMI) of 40 or more or a BMI of

35 if co-morbidities exist;

• 18 years old or have documentation of completion

of Bone Growth;

• Failed attempted weight loss under the direction of

MD or Presurgical weight loss regime;

• Pre-operative psychological evaluation.

Note: Bariatric surgery requires our prior approval.

See Services requiring our prior approval on page 16.

$15 per office visit to your

primary care physician or $30

per visit to a specialist

Nothing for the physician’s

charge for surgery

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductible. The deductible

applies to all services billed by

a hospital.

$20 per office visit to your

primary care physician or $50

per visit to a specialist

Nothing for the physician’s

charge for surgery

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductible. The deductible

applies to all services billed by

a hospital.

Not covered:

•

Reversal of voluntary sterilization

•

Routine treatment of conditions of the foot; see

Foot care

All Charges All Charges

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

- the condition can reasonably be expected to be

corrected by such surgery

$15 per office visit to your

primary care physician or $30

per visit to a specialist

Nothing for the physician’s

charge for surgery

$20 per office visit to your

primary care physician or $50

per visit to a specialist

Nothing for the physician’s

charge for surgery

Reconstructive surgery - continued on next page

37 2013 Coventry Health Plan of Florida Section 5(b)

High and Standard Option

Benefit Description You pay

Reconstructive surgery (cont.) High Option Standard Option

• Surgery to correct a codition 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

palate; birth marks; and webbed fingers and toes.

• All stages of breast recontruction 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.

$15 per office visit to your

primary care physician or $30

per visit to a specialist

Nothing for the physician’s

charge for surgery

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductible. The deductible

applies to all services billed by

a hospital.

$20 per office visit to your

primary care physician or $50

per visit to a specialist

Nothing for the physician’s

charge for surgery

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductible. The deductible

applies to all services billed by

a hospital.

Not covered:

•

Cosmetic surgery – any surgical procedure (or any

portion of a procedure) performed primarily to

improve physical appearance through change in

bodily form, except repair of accidental injury

•

Surgeries related to sex transformation

All Charges All Charges

Oral and maxillofacial surgery High Option Standard Option

Oral surgical procedures, limited to:

• Reduction of fractures of the jaws or facial bones;

• Surgical correction of cleft lip, cleft palate or

severe functional malocclusion;

• Removal of stones from salivary ducts;

• Excision of leukoplakia or malignancies;

• 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.

$15 per office visit to your

primary care physician or $30

per visit to a specialist

Nothing for the physician’s

charge for surgery

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductible. The deductible

applies to all services billed by

a hospital.

$20 per office visit to your

primary care physician or $50

per visit to a specialist

Nothing for the physician’s

charge for surgery

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductible. The deductible

applies to all services billed by

a hospital.

Not covered

•

Oral implants and transplants

•

Procedures that involve the teeth or their

supporting structures (such as the periodontal

membrane, gingiva, and alveolar bone)

All charges All charges

38 2013 Coventry Health Plan of Florida Section 5(b)

High and Standard Option

Benefit Description You pay

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 HealthAmerica member approved for transplant

services.

Solid organ transplants limited to:

• Cornea

• Heart

• Heart/lung

• Intestinal transplants

- 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 toal or near total pancreatectomy)

only for patients with chronic pancreatitis.

• Kidney

• Liver

• Lung: single/bilateral/lobar

• Pancreas

• Autologous pancreas islet cell transplant (as an

adjunct to total or near total pancreatectomy) only

for patients with chronic pancreatitis

* 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 in ineffective.

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. These transplants are limited to the stages

of the following diagnoses. The medical necessity is

considered satisfied if the patient meets the staging

description.

• Autologous tandem transplants for

$15 per office visit to your

primary care physician or $30

per visit to a specialist

Nothing for the physician's

charge for surgery.

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductible. The deductible

applies to all services billed by

a hospital.

$20 per office visit to your

primary care physician or $50

per visit to a specialist

Nothing for the physician's

charge for surgery.

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductible. The deductible

applies to all services billed by

a hospital.

Organ/tissue transplants - continued on next page

39 2013 Coventry Health Plan of Florida Section 5(b)

High and Standard Option

Benefit Description You pay

Organ/tissue transplants (cont.) High Option Standard Option

- AL Amyloidosis

- Multiple myeloma (de novo and treated)

- Recurrent germ cell tumors (including testicular

cancer)

$15 per office visit to your

primary care physician or $30

per visit to a specialist

Nothing for the physician's

charge for surgery.

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductible. The deductible

applies to all services billed by

a hospital.

$20 per office visit to your

primary care physician or $50

per visit to a specialist

Nothing for the physician's

charge for surgery.

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductible. The deductible

applies to all services billed by

a hospital.

Blood or marrow stem cell transplants limited to

the stages of the following disgnoses. For the

diagnoses listed below, the medical necessity

limitation is considered satisfied if the patient meets

the staging description.

Allogeneic (donor) transplants for:

• Acute lymphocytic or non-lymphocytic (i.e.,

myelogenous) leukemia

• Advanced Hodgkin's lymphoma with reoccurrence

(relapsed)

• Advanced non-Hodgkin's lymphoma with

reoccurrence (relapsed)

• Acute myeloid leukemia

• Advanced Myeloproliferative Disorders (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)

• 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

$15 per office visit to your

primary care physician or $30

per visit to a specialist

Nothing for the physician's

charge for surgery.

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductible. The deductible

applies to all services billed by

a hospital.

$20 per office visit to your

primary care physician or $50

per visit to a specialist

Nothing for the physician's

charge for surgery.

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductible. The deductible

applies to all services billed by

a hospital.

Organ/tissue transplants - continued on next page

40 2013 Coventry Health Plan of Florida Section 5(b)

High and Standard Option

Benefit Description You pay

Organ/tissue transplants (cont.) High Option Standard Option

• Phagocytic/Hemophagocytic deficiency diseases

(e.g., Wiskott-Aldrich syndrome)

• Severe combined immunodeficiency

• Severe or very severe aplastic anemia

• Sickle cell anemia

• X-linked lymphoproliferative syndrome

Autologous transplants for

• Acute lymphocytic or nonlymphocytic (i.e.,

myelogenous) leukemia

• Advanced Hodgkin’s lymphoma with reoccurrence

(relapsed)

• Advanced non-Hodgkin’s lymphoma with

reoccurrence (relapsed)

• Amyloidosis

• Breast Cancer

• Ependymoblastoma

• Epithelial ovarian cancer

• Ewing's sarcoma

• Multiple myeloma

• Medulloblastoma

• Pineoblastoma

• Neuroblastoma

• Testicular, Mediastinal, Retroperitoneal, and

ovarian germ cell tumors

$15 per office visit to your

primary care physician or $30

per visit to a specialist

Nothing for the physician's

charge for surgery.

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductible. The deductible

applies to all services billed by

a hospital.

$20 per office visit to your

primary care physician or $50

per visit to a specialist

Nothing for the physician's

charge for surgery.

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductible. The deductible

applies to all services billed by

a hospital.

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:

Allogenic transplants for

• Acute lymphocytic or non-lymphocytic (i.e.,

myelogenous) leukemia

• Advanced Hodgkin's lymphoma with reoccurance

(relapsed)

• Advanced non-Hodgkin's lymphoma with

reoccurance (relapsed)

• Acute myeloid leukemia

• Advanced Myeloproliferative Disorders (MPDs)

• Amyloidosis

$15 per office visit to your

primary care physician or $30

per visit to a specialist

Nothing for the physician's

charge for surgery

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductibe. The deductible

applies to all services billed by

a hospital.

$20 per office visit to your

primary care physician or $50

per visit to a specialist

Nothing for the physician's

charge for surgery

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductibe. The deductible

applies to all services billed by

a hospital.

Organ/tissue transplants - continued on next page

41 2013 Coventry Health Plan of Florida Section 5(b)

High and Standard Option

Benefit Description You pay

Organ/tissue transplants (cont.) High Option Standard Option

• Chronic lymphocytic leukemia/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 Homoglobinuria

• Severe combined immunodeficiency

• Severe or very severe aplastic anemia

Autologous transplants for

• Acute lymphocytic or nonlymphocytic (i.e.,

myelogenous) leukemia

• Advanced Hodgkin's lymphoma with reoccurence

(relapsed)

• Advanced non-Hodgkin's lymphoma with

reoccurence (relapsed)

• Amyloidosis

• Neuroblastoma

$15 per office visit to your

primary care physician or $30

per visit to a specialist

Nothing for the physician's

charge for surgery

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductibe. The deductible

applies to all services billed by

a hospital.

$20 per office visit to your

primary care physician or $50

per visit to a specialist

Nothing for the physician's

charge for surgery

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductibe. The deductible

applies to all services billed by

a hospital.

These blood or marrow stem cell transplants covered

only in a National Cancer Institute or National

Institutes of health approved clinical trial or a Plan-

designated center of excellence and if approved by

the Plan's medical director in accordance with the

Plan's protocols.

If you are a participant in a clinical trial, the Plan will

provide benefits for related routine care that is

medically 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

• The trial is approved by the Plan's Medical

Director in accordance with the Plan's protocals.

Allogeneic transplants for

• Advanced Hodgkin's lymphoma

• Advanced non-Hodgkin's lymphoma

• Beta Thalassemia Major

$15 per office visit to your

primary care physician or $30

per visit to a specialist

Nothing for the physician's

charge for surgery

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductibe. The deductible

applies to all services billed by

a hospital.

$20 per office visit to your

primary care physician or $50

per visit to a specialist

Nothing for the physician's

charge for surgery

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductibe. The deductible

applies to all services billed by

a hospital.

Organ/tissue transplants - continued on next page

42 2013 Coventry Health Plan of Florida Section 5(b)

High and Standard Option

Benefit Description You pay

Organ/tissue transplants (cont.) High Option Standard Option

• Chronic inflammatory demyelination

polyneuropathy (CIDP)

• Early stage (indolent or non-advanced) small cell

lymphocytic lymphoma

• Multiple myeloma

• Multiple sclerosis

• Sickle Cell anemia

Mini-transplants (non-myeloblative allogenic,

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 disorders (MDDs)

• Myelodysplasia/Myelodysplastic Syndromes

• Non-small lung cancer

• Ovarian cancer

• Prostate cancer

• Renal cell carcinoma

• Sarcomas

• Sickle cell anemia

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)

$15 per office visit to your

primary care physician or $30

per visit to a specialist

Nothing for the physician's

charge for surgery

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductibe. The deductible

applies to all services billed by

a hospital.

$20 per office visit to your

primary care physician or $50

per visit to a specialist

Nothing for the physician's

charge for surgery

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductibe. The deductible

applies to all services billed by

a hospital.

Organ/tissue transplants - continued on next page

43 2013 Coventry Health Plan of Florida Section 5(b)

High and Standard Option

Benefit Description You pay

Organ/tissue transplants (cont.) High Option Standard Option

• Early stage (indolent or non-advanced) small cell

lymphocytic lymphoma

• Epithelial Ovarian Cancer

• Mantle Cell (Non-Hodgkin lymphoma)

• Multiple sclerosis

• Small cell lung cancer

• Systemic lupus erythematosus

• Systemic sclerosis

$15 per office visit to your

primary care physician or $30

per visit to a specialist

Nothing for the physician's

charge for surgery

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductibe. The deductible

applies to all services billed by

a hospital.

$20 per office visit to your

primary care physician or $50

per visit to a specialist

Nothing for the physician's

charge for surgery

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductibe. The deductible

applies to all services billed by

a hospital.

Coventry Transplant Network (CTN) -

NOTE: We cover related medical and hospital

expenses of the donor when we cover the recipient.

We cover donor screening tests and donor search

expenses for the actual solid organ or up to four bone

marrow/stem cell transplant donors in addition to the

testing of family members.

Not covered:

•

Donor screening tests and donor search expenses,

except as those shown above

•

Donor expenses related to donating organs or tissue

to a non-member recipient

•

Implants of artificial organs

•

Transplants not specifically listed as covered

All charges All charges

Anesthesia High Option Standard Option

Professional services provided in –

• Hospital (inpatient)

• Hospital outpatient department

• Skilled nursing facility

Note: See Section 5 (c) for

information on the applicable

facility copayment and annual

deductible. The deductible

applies to all services billed by

a hospital.

Note: See Section 5 (c) for

information on the applicable

facility copayment and annual

deductible. The deductible

applies to all services billed by

a hospital.

Professional services provided in –

• Office

$15 per office visit to your

primary care physician or $30

per visit to a specialist

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductible. The deductible

applies to all services billed by

a hospital.

$20 per office visit to your

primary care physician or $50

per visit to a specialist

Note: See Section 5(c) for

information on the applicable

facility copayment and annual

deductible. The deductible

applies to all services billed by

a hospital.

44 2013 Coventry Health Plan of Florida 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.

•In this Section, unlike Sections 5(a) and 5(b), the hospital deductible applies to only a few benefits.

We added “(hospital deductible applies)” when it applies. The hospital deductible is: $250 per

person on the High Option or $500 per person on the Standard Option.

•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

Note: The hospital deductible applies only when we say below: "(hospital deductible applies)".

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.

$150 per day up to a maximum

of $450 after $250 hospital

deductible per person is

satisfied

$150 per day for the first five

days after $500 hospital

deductible per person is

satisfied

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment

rooms

• Prescribed drugs and medicines

• Diagnostic laboratory tests and X-rays

• Dressings, splints, casts, and sterile tray services

• Medical supplies and equipment, including oxygen

• Blood or blood plasma, if not donated or replaced

• Administration of blood and blood products

• Anesthetics, including nurse anesthetist services

• Take-home items

• Medical supplies, appliances, medical equipment,

and any covered items billed by a hospital for use

at home (Note: hospital deductible applies.)

Nothing after the inpatient

hospital copay and the $250

hospital deductible per person

Nothing after the inpatient

hospital copay and the $500

hospital deductible per person

Inpatient hospital - continued on next page

45 2013 Coventry Health Plan of Florida Section 5(c)

High and Standard Option

Benefit Description You pay

Inpatient hospital (cont.) High Option Standard Option

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

• Blood and blood plasma, if not donated or replaced

• 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 copay for outpatient

surgery performed at a

freestanding participating

facility

$100 copay after the $250

hospital deductible for services

performed in a hospital setting

$150 copay for outpatient

surgery performed at a

freestanding participating

facility

$250 copay after the $500

hospital deductible for services

performed in a hospital setting

Not covered: Blood and blood derivatives replaced by

the member

All Charges All Charges

Extended care benefits/Skilled nursing care

facility benefits

High Option Standard Option

The plan provides a comprehensive range of benefits

for up to 100 days per calendar year when you are

hospitalized under the care of a Plan physician. All

medically necessary services are covered.

• Bed, board and general nursing care

• Drugs, biological, supplies and equipment

ordinarily provided or arranged by the skilled

nursing facility when prescribed by a Plan

physician.

Nothing Nothing

Not covered: Custodial care All Charges All Charges

46 2013 Coventry Health Plan of Florida Section 5(c)

High and Standard Option

Benefit Description You pay

Hospice care High Option Standard Option

Hospice care: up to 210 days per lifetime

The Plan covers supportive and palliative care for a

terminally ill member. Coverage is provided in the

home or a hospice facility. Services include inpatient,

outpatient care and family counseling; these services

are provided under the direction of a Plan physician

who certifies that the patient is in terminal stages of

illness, with a life expectancy of approximately six

months or less.

Nothing Nothing

Not covered: Independent nursing, homemaker

services

All Charges All Charges

Ambulance High Option Standard Option

• Local professional ambulance service when

medically appropriate

• Air Ambulance limited to situation where ground

transportation is not medically appropriate – prior

plan authorization required.

Note: See 5(d) for non-emergency service.

Nothing Nothing

47 2013 Coventry Health Plan of Florida Section 5(c)

Section 5(d). Emergency services/accidents

High and Standard Option

Important things you should keep in mind about these benefits:

•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this

brochure and are payable only when we determine they are medically necessary.

•We do not have a hospital deductible for emergency room services.

•Be sure to read Section 4,

Your costs for covered services,

for valuable information about how cost-

sharing works. Also read Section 9 about coordinating benefits with other coverage, including with

Medicare.

What is a medical emergency?

A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or

could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies

because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are

emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or

sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies – what

they all have in common is the need for quick action.

What to do in case of emergency:

If you are in an emergency situation, please call your primary doctor. In extreme emergencies, if you are unable to contact

your doctor, 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. You or a family

member should notify the Plan within 48 hours unless it is not reasonably possible to do so. It is your responsibility to ensure

that the Plan has been notified timely.

If you need to be hospitalized, the Plan must be notified within 48 hours or the first working day following your admission,

unless it is not reasonably possible to notify the Plan in 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

ambulance charges covered in full.

Emergencies within our service area: Benefits are available for care from non-Plan provider in a medical emergency only

if delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition.

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 service that is immediately

required because of injury or unforeseen illness.

If you need to be hospitalized, the Plan must be notified within 48 or on the first working day following your admission,

unless it was not reasonably possible to notify the Plan in 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.

48 2013 Coventry Health Plan of Florida 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 $15 per visit to primary care

physician / $30 per visit to

specialist

$20 per visit to primary care

physician / $50 per visit to

specialist

• Emergency care at an urgent care center $40 per visit $50 per visit

• Emergency care as an outpatient or inpatient at a

hospital, including doctors’ services

Note: We waive the ER copay if you are admitted to

the hospital.

$150 per visit $150 per visit

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 $15 per visit to PCP / $30 per

visit to Specialist

$20 per visit to PCP / $50 per

visit to Specialist

• Emergency care at an urgent care center $40 per visit $50 per visit

• Emergency care as an outpatient at a hospital,

including doctors' services

$150 per hospital emergency

room visit

$150 per hospital emergency

room 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

Ambulance High Option Standard Option

• Professional ambulance service when medically

appropriate.

• Air Ambulance limited to situation where ground

transportation is not

medically appropriate – prior plan authorization

required.

Note: See 5(d) for non-emergency service.

Nothing Nothing

49 2013 Coventry Health Plan of Florida Section 5(d)

Section 5(e). Mental health and substance abuse benefits

High and Standard Option

You need to get Plan approval (preauthorization) for services and follow a treatment plan we approve

in order to get benefits. When you receive services as part of an approved treatment plan, cost-sharing

and limitations for Plan mental health and substance abuse benefits are no greater than for similar

benefits for other illnesses and conditions.

Important things you should keep in mind about these benefits:

•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this

brochure and are payable only when we determine they are medically necessary.

•All services provided in a hospital setting are subject to the hospital deductible, $250 per person

under High Option or $500 per person under Standard Option. Daily copayments for inpatient

hospital admissions and other facility charges may also apply.

•Be sure to read Section 4,

Your costs for covered services

, for valuable information about how cost-

sharing works. Also read Section 9 about coordinating benefits with other coverage, including with

Medicare.

•YOU MUST GET PREAUTHORIZATION FOR THESE SERVICES. Benefits are payable

only when we determine the care is clinically appropriate to treat your condition and only when you

receive the care as part of a treatment plan that we approve. The treatment plan may include

services, drugs, and supplies described elsewhere in this brochure. To be eligible to receive full

benefits, you must follow the preauthorization process and get Plan approval of your treatment plan:

•We will provide medical review criteria or reasons for treatment plan denials to enrollees, members

or providers upon request or as otherwise required.

•OPM will base its review of disputes about treatment plans on the treatment plan’s clinical

appropriateness. OPM will generally not order us to pay or provide one clinically appropriate

treatment plan in favor of another.

Benefit Description You pay

Note: The hospital deductible applies to almost all benefits in this Section.

We say “(No deductible)” when it does not apply.

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.

Your cost-sharing

responsibilities are no greater

than for other illnesses or

conditions.

Your cost-sharing

responsibilities are no greater

than for other illnesses or

conditions.

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)

$15 per office visit to your

primary care physician and $30

per office visit to a specialist

$20 per office visit to your

primary care physician and $50

per office visit to a specialist

Professional services - continued on next page

50 2013 Coventry Health Plan of Florida Section 5(e)

High and Standard Option

Benefit Description You pay

Professional services (cont.) High Option Standard Option

• Diagnosis and treatment of alcoholism and drug

abuse, including detoxification, treatment and

counseling

• Professional charges for intensive outpatient

treatment in a provider's office or other

professional setting

• Electroconvulsive therapy

$15 per office visit to your

primary care physician and $30

per office visit to a specialist

$20 per office visit to your

primary care physician and $50

per office visit to a specialist

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

$15 per office visit to your

primary care physician and $30

per office visit to a specialist

Nothing when performed at a

participating free-standing

laboratory center

After the $250 hospital

deductible, nothing for services

performed and billed by a

hospital

$20 per office visit to your

primary care physician and $50

per office visit to a specialist

$50 when performed at a

participating free-standing

laboratory center

After the $500 hospital

deductible, nothing for services

performed and billed by a

hospital

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

accomodations, general nursing care, meals and

special diets, and other hospital services

$150 per day for the first three

(3) days per admission, after

you have satisfied a $250

hospital deductible

$150 per day for the first five

(5) days per admission, after

you have satisfied a $500

hospital deductible

Not covered High Option Standard Option

Services that are not part of a preauthorized approved

treatment plan.

Note: 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.

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:

Prior to seeking mental health and substance abuse treatment, you must call Psych/Care at

1-800-221-5487. Psych/Care is a managed behavioral health care firm with over 500

providers in our service area. You do not need a referral from your primary care physician

or authorization from us. A Psych/Care provider will evaluate you and develop a treatment

plan.

Once the treatment plan has been approved, you must follow it. If you need inpatient care,

your Psych/Care provider will arrange it for you. Call Psych/Care for a list of participating

providers in your area.

Preauthorization

We may limit your benefits if you do not obtain a treatment plan. Limitation

51 2013 Coventry Health Plan of Florida Section 5(e)

Section 5(f). Prescription drug benefits

High and Standard Option

Important things you should keep in mind about these benefits:

•We cover prescribed drugs and medications, as described in the chart beginning on the next page.

•Please remember that all benefits are subject to the definitions, limitations and exclusions in this

brochure and are payable only when we determine they are medically necessary.

•Certain drugs require prior authorization from us. Your physician must obtain our prior authorization

for certain drugs and all Tier IV high technology and self-administered drugs.

•We do not have a calendar year deductible for prescription drugs.

•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 plan physician or licensed dentist must write the prescription.

•Where you can obtain them. You may fill the prescription at a participating pharmacy. Please see the complete listing of

participating pharmacies in our provider directory.

•We use a formulary. The formulary is a list of medications, both brand and generic, that we approve as covered

medication. Plan pharmacies dispense prescription medication to our members based on our formulary list. However, we

cover non-formulary drugs prescribed by a Plan doctor. You must pay a higher copay for non-formulary drugs. Our

formulary has 5 tiers of prescription drug coverage. Tier 1A includes low cost select generic drugs. Tier 1B includes low

cost generic formulary drugs. Tier 2 includes brand name formulary drugs. Tier 3 includes high cost, mostly brand name

non-formulary drugs that usually have generic or brand name alternatives in Tiers 1 or 2. Tier 4 includes high technology

and self-administered drugs, including growth hormone. Tier 4 drugs require our prior authorization. If you’d like a copy

of our formulary, please call us at 1-866-575-1882.

•These are the dispensing limitations.You may obtain a 30-day supply at a Plan pharmacy or a 90-day supply via mail

order. Mail order is available for maintenance medications only. A 90-day vacation supply may also be obtained from a

Plan pharmacy once a year. Plan pharmacies will not dispense refills in excess of the number specified by the physician or

refill medication more than 12 months after the original date of the prescription. You may obtain a refill up to 6 days

before your prescription runs out. A generic equivalent will be dispensed if it is available, unless your physician

specifically requires a name brand drug. When your physician requires a name brand drug, the physician must specify

“Dispense as Written” on the prescription or you will have to pay the difference in cost between the name brand drug and

the generic.

•Prior authorization process for medication other than self-injectable drugs. Our prescription drug formulary is based

on the principles of providing and promoting safe, efficacious and cost-effective medications for our members. In order to

monitor drug therapy duplication, abuse, misuse, and interactions, we administer a prior authorization (PA) requirement

for certain drugs. Our prior authorization program operates in the following manner.

We provide our participating physicians with a list of medications that require our prior authorization before they can be

dispensed by a Plan pharmacy. Your Plan physician must complete and submit a PA form to Coventry Health Care of Florida

(Coventry) to begin the authorization process. If you try to fill the prescription at a pharmacy and we have not authorized the

medication, the pharmacist will advise you that your physician must obtain prior authorization for the medication before it

can be dispensed. Your physician should call 1-866-847-8279 to obtain a PA form and must complete and fax it to

954-858-3386. If PA is urgent and you need the medication immediately, the physician can call the Rx phone number and

speak to a Coventry's clinical pharmacist during office hours. After office hours, pharmacies can call Coventry’s round-the-

clock Pharmacy Benefit Manager at 1-800-922-1557 to obtain an authorization for a one-time 7-day supply of a non-

formulary medication.

52 2013 Coventry Health Plan of Florida Section 5(f)

High and Standard Option

•Prior authorization process for self-injectable drugs. The prior approval process for requesting self-injectable

medication is very similar to PA for other medication. The only difference is that the prescription must be filled by a

Specialty Pharmacy. The physician completes a request form and faxes it to the Specialty Pharmacy and the specialty

pharmacy forwards it to Coventry’s Pharmacy Department for approval. If you have any questions about the prior

authorization process, please contact 1-866-575-1882.

•Why use generic drugs? Generic drugs offer a safe and economic way to meet your prescription drug needs. The generic

name of a drug is its chemical name; the name brand is the name under which the manufacturer advertises and sells a drug.

Under federal law, generic and name brand drugs must meet the same standards for safety, purity, strength, and

effectiveness. A generic prescription costs you – and us – less than a name brand prescription.

•When you do have to file a claim. There are no claims to file when you use a Plan pharmacy or our mail order program.

If you have an emergency while outside our service area, and you fill a prescription at a non-Plan pharmacy, you must

submit a claim for reimbursement. We will reimburse up to the amount we would have paid if you had used a plan

pharmacy.

•If you are a military reservist called to active duty or are a member requiring a supply of medication during a

national emergency, call us at 1-866-847-8279 for assistance with obtaining your medication.

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 those listed as

Not covered.

• Insulin

• Disposable needles and syringes for the

administration of covered medications

• Diabetic supplies, including insulin syringes,

needles, glucose test tablets, test strips, and

solution

• Drugs for sexual dysfunction

Note: Drugs for sexual dysfunctions have special

dispensing limits and guidelines. Please contact us for

details. These drugs are not available under our mail-

order program.

Note: Tier 4 includes: High technology and select

self-injectable specialty pharmacy medications. These

drugs are not available under our mail-order program.

Tier 4 drugs require our prior authorization. We

periodically review and update the list of

medications. Please contact us to verify if your drug

is on Tier 4. These drugs have specific characteristics

such as: usually injectable; high in cost; and require

special handling and special training to use.

Retail Pharmacy (up to 30-day

supply per prescription unit or

refill):

• Tier 1A - $3; select generic

formulary;

• Tier 1B - $20; generic

formulary;

• Tier 2 - $40; name brand

formulary;

• Tier 3 - $60; non-formulary;

• Tier 4 - 20% of negotiated

rate up to $100 per month

out-of-pocket limit to a

maximum of $1,200 per

calendar year (except for

diabetic supplies). Tier 4

drugs require prior

authorization.

Note: If there is no generic

equivalent available, you will

still have to pay the brand name

or non-formulary copay.

Mail-Order Pharmacy (up to

a 90-day supply of maintenance

medication):

• Tier 1A - $3; select generic

formulary;

• Tier 1B - $60; generic

formulary;

• Tier 2 - $120; name brand

formulary;

Retail Pharmacy (up to 30-day

supply per prescription unit or

refill):

• Tier 1A - $3; select generic

formulary;

• Tier 1B - $10; generic

formulary;

• Tier 2 - $50; name brand

formulary;

• Tier 3 - $70; non-formulary;

• Tier 4 - 20% of negotiated

rate up to $100 per month

out-of-pocket limit to a

maximum of $1,200 per

calendar year (except for

diabetic supplies). Tier 4

drugs require prior

authorization.

Note: If there is no generic

equivalent available, you will

still have to pay the brand name

or non-formulary copay.

Mail-Order Pharmacy (up to

a 90-day supply of maintenance

medication):

• Tier 1A - $3; select generic

formulary;

• Tier 1 - $10 generic

formulary;

• Tier 2 - $100 name brand

formulary;

Covered medications and supplies - continued on next page

53 2013 Coventry Health Plan of Florida Section 5(f)

High and Standard Option

Benefit Description You pay

Covered medications and supplies (cont.) High Option Standard Option

• Tier 3 - $180; non-formulary.

Note: We have no Tier 4 under

mail-order. Therefore, high

technology and self-injectable

specialty pharmacy medications

are available through Tier 4

retail.

• Tier 3 - $210 non-formulary.

Note: We have no Tier 4 under

mail-order. Therefore, high

technology and self-injectable

specialty pharmacy medications

are available through Tier 4

retail.

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 provide

(See Page 35).

• Drugs for smoking cessation

(combined with all Tobacco

cessation services) including

"Over the Counter" (OTC)

products require a script to

obtain with no charge.

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 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.

• All OTC products have the

same indication.

• Drugs for smoking cessation

(combined with all smoking

cessation services) including

"Over the Counter" (OTC)

products require a script to

obtain with no charge.

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 OTC smoking

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.

• All OTC products have the

same indication.

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

•

Nonprescription medicines

All Charges All Charges

Covered medications and supplies - continued on next page

54 2013 Coventry Health Plan of Florida Section 5(f)

High and Standard Option

Benefit Description You pay

Covered medications and supplies (cont.) High Option Standard Option

•

Drugs given to you while you are a patient in a

hospital, skilled nursing facility, convalescent

hospital, hospice or other facility where drugs are

ordinarily provided by the facility to its patients.

•

Refills in excess of the number specified by the

physician or refills dispensed more than 12 months

after the the original date of the prescription.

•

Drugs provided to you by this plan, but which are

lost, stolen or destroyed.

•

Drugs for the treatment of obesity, unless

medically necessary for the treatment or morbid

obesity.

All Charges All Charges

55 2013 Coventry Health Plan of Florida Section 5(f)

Section 5(g). Dental benefits

High and Standard Option

Important things you should keep in mind about these benefits:

•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this

brochure and are payable only when we determine they are medically necessary.

•If you are enrolled in a Federal Employees Dental/Vision Insurance Program (FEDVIP) Dental

Plan, your FEHB Plan will be First/Primary payor of any Benefit payments and your FEDVIP Plan

is secondary to your FEHB Plan. See Section 9 Coordinating benefits with other coverage.

•Plan dentists must provide or arrange your care.

•We cover hospitalization for dental procedures only when a non-dental physical impairment exists

which makes hospitalization necessary to safeguard the health of the patient. See Section 5(c) for

inpatient hospital benefits. We do not cover the dental procedure unless it is described below.

•Be sure to read Section 4,

Your costs for covered services,

for valuable information about how cost-

sharing works. Also read Section 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.

$30 per office visit $50 per office visit

56 2013 Coventry Health Plan of Florida Section 5(g)

Section 5(h). Special features

High and Standard Option

Feature Description

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

If you are hearing or speech impaired and use a telephone device for the deaf, you may

call 1-888-444-7352 Monday through Friday from 8 a.m. to 6 p.m.

Services for deaf and

hearing impaired

Coventry Health Care of Florida offers a dedicated OB Case Management unit,

coordinating and monitoring all phases of care through the member’s pregnancy.

High risk pregnancies

Coventry Health Care of Florida utilizes Centers of Excellence for transplant services.

Please call us at 1-866-575-1882 for more information.

Centers of excellence for

transplants

Limited to ER services world-wide must submit translated documents. (E.R. notes,

receipts of paid services)

Travel benefit/services

overseas

57 2013 Coventry Health Plan of Florida Section 5(h)

Table of contents

See page 14 for how our benefits changed this year. Pages 119 are a benefits summary of this option. Make sure that you

review the benefits that are available under the option in which you are enrolled.

Section 5. High Deductible Health Plan Benefits Overview ......................................................................................................60

Section 5. Savings – HSAs and HRAs ........................................................................................................................................63

Section 5. Preventive care ...........................................................................................................................................................68

Section 5. Traditional medical coverage subject to the deductible .............................................................................................71

Section 5(a). Medical services and supplies provided by physicians and other health care professionals .................................72

• Diagnostic and treatment services ................................................................................................................................72

• Lab, X-ray and other diagnostic tests ...........................................................................................................................72

• Maternity care ...............................................................................................................................................................72

• Family planning ............................................................................................................................................................73

• Infertility services .........................................................................................................................................................73

• Allergy care ...................................................................................................................................................................74

• Treatment therapies .......................................................................................................................................................74

• Physical and occupational therapies .............................................................................................................................74

• Hearing services (testing, treatment, and supplies) ......................................................................................................75

• Vision services (testing, treatment, and supplies) .........................................................................................................75

• Foot care .......................................................................................................................................................................76

• Orthopedic and prosthetic devices ................................................................................................................................76

• Durable medical equipment (DME) .............................................................................................................................76

• Home health services ....................................................................................................................................................77

• Chiropractic ..................................................................................................................................................................77

• Alternative treatments ...................................................................................................................................................78

• Educational classes and programs ................................................................................................................................78

Section 5(b). Surgical and anesthesia services provided by physicians and other health care professionals ............................79

• Surgical procedures ......................................................................................................................................................79

• Reconstructive surgery .................................................................................................................................................80

• Oral and maxillofacial surgery .....................................................................................................................................81

• Organ/tissue transplants ................................................................................................................................................81

• Anesthesia .....................................................................................................................................................................85

Section 5(c). Services provided by a hospital or other facility, and ambulance services ...........................................................86

• Inpatient hospital ..........................................................................................................................................................86

• Outpatient hospital or ambulatory surgical center ........................................................................................................87

• Extended care benefits/Skilled nursing care facility benefits .......................................................................................87

• Hospice care .................................................................................................................................................................87

• Ambulance ....................................................................................................................................................................87

Section 5(d). Emergency services/accidents ...............................................................................................................................88

• Emergency within our service area ...............................................................................................................................89

• Emergency outside our service area .............................................................................................................................89

• Ambulance ....................................................................................................................................................................89

Section 5(e). Mental health and substance abuse benefits ..........................................................................................................90

• Professional services .....................................................................................................................................................90

• Diagnostics ...................................................................................................................................................................91

• Inpatient hospital or other covered facility ...................................................................................................................91

• Not covered ...................................................................................................................................................................91

Section 5(f). Prescription drug benefits ......................................................................................................................................92

58 2013 Coventry Health Plan of Florida

• Covered medications and supplies ...............................................................................................................................93

Section 5(g). Dental benefits .......................................................................................................................................................95

• Accidental injury benefit ..............................................................................................................................................95

Section 5(h). Special features ......................................................................................................................................................96

• Flexible benefits option ................................................................................................................................................96

• Services for deaf and hearing impaired ........................................................................................................................96

• High risk pregnancies ...................................................................................................................................................96

• Centers of excellence ....................................................................................................................................................96

• Travel benefit/services overseas ...................................................................................................................................96

Summary of benefits for the HDHP for Coventry Health Plan of Florida 2013 .......................................................................119

59 2013 Coventry Health Plan of Florida

Section 5. High Deductible Health Plan Benefits Overview

This Plan offers a High Deductible Health Plan (HDHP). The HDHP benefit package is described in this section.

Make sure that you review the benefits that are available under the benefit product in which you are enrolled.

HDHP Section 5, which describes the HDHP benefits, is divided into subsections. Please read

Important things you should

keep in mind about these benefits

at the beginning of each subsection. Also read the General Exclusions in Section 6; they

apply to benefits in the following subsections. To obtain claim forms, claims filing advice, or more information about HDHP

benefits, contact us at 866-575-1882 or at our Web site at feds.chcflorida.com.

Our HDHP option provides comprehensive coverage for high-cost medical events and a tax-advantaged way to help you

build savings for future medical expenses. The Plan gives you greater control over how you use your health care benefits.

When you enroll in this HDHP, we establish either a Health Savings Account (HSA) or a Health Reimbursement

Arrangement (HRA) for you. We automatically pass through a portion of the total health Plan premium to your HSA or

credit an equal amount to your. HRA based upon your eligibility. Your full annual HRA credit will be available on your

effective date of enrollment.

With this Plan preventive care is covered in full. As you receive other non-preventive medical care, you must meet the Plan's

deductible before we pay benefits according to the benefit chart on page 68. You can choose to use funds available in your

HSA to make payments toward the deductible or you can pay toward your deductible entirely out-of-pocket, allowing your

savings to continue to grow.

This HDHP includes five key components: preventive care; traditional medical coverage health care that is subject to the

deductible; savings; catastrophic protection for out-of-pocket expenses; and health education resources and account

management tools.

The Plan covers preventive care services, such as periodic health evaluations (e.g., annual

physicals), screening services (e.g., mammograms), routine prenatal and well-child care,

child and adult immunizations, tobacco cessation programs, obesity weight loss programs,

disease management and wellness programs. These services are covered at 100% if you

use a network provider and the services are described in Section 5

Preventive care

You

do not have to meet the deductible before using these services.

Preventive care

After you have paid the Plan’s deductible, we pay benefits under traditional medical

coverage described in Section 5. The Plan typically pays 80% for in-network.

Covered services include:

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

professionals

• Surgical and anesthesia services provided by physicians and other health care

professionals

• Hospital services; other facility or ambulance services

• Emergency services/accidents

• Mental health and substance abuse benefits

• Prescription drug benefits

• Dental benefits

Traditional medical

coverage

Health Savings Accounts or Health Reimbursement Arrangements provide a means to

help you pay out-of-pocket expenses (see page 63 for more details).

Savings

60 2013 Coventry Health Plan of Florida Section 5 High Deductible Health Plan

By law, HSAs are available to members who are not enrolled in Medicare, cannot be

claimed as a dependent on someone else’s tax return, have not received VA Indian Health

Services (IHS) benefits within the last three months or do not have other health insurance

coverage other than another high deductible health plan. In 2013, for each month you are

eligible for an HSA premium pass through, we will contribute to your HSA $83.34 per

month for a Self Only enrollment or $166.67 per month for a Self and Family enrollment.

In addition to our monthly contribution, you have the option to make additional tax-free

contributions to your HSA, so long as total contributions do not exceed the limit

established by law, which is $3,250 for an individual and $6,450 for a family. See

maximum contribution information on page 66. You can use funds in your HSA to help

pay your health plan deductible. You own your HSA, so the funds can go with you if you

change plans or employment.

Federal tax tip: There are tax advantages to fully funding your HSA as quickly as

possible. Your HSA contribution payments are fully deductible on your Federal tax

return. By fully funding your HSA early in the year, you have the flexibility of paying

medical expenses from tax-free HSA dollars or after tax out-of-pocket dollars. If you

don’t deplete your HSA and you allow the contributions and the tax-free interest to

accumulate, your HSA grows more quickly for future expenses.

HSA features include:

• Your HSA is administered by Health Equity

• Your contributions to the HSA are tax deductible

• You may establish pre-tax HSA deductions from your paycheck to fund your HSA up

to IRS limits using the same method that you use to establish other deductions (i.e.,

Employee Express, MyPay, etc.)

• Your HSA earns tax-free interest

• You can make tax-free withdrawals for qualified medical expenses for you, your

spouse and dependents (see IRS publication 502 for a complete list of eligible

expenses)

• Your unused HSA funds and interest accumulate from year to year

• It’s portable - the HSA is owned by you and is yours to keep, even when you leave

Federal employment or retire

• When you need it, funds up to the actual HSA balance are available.

Important consideration if you want to participate in a Health Care Flexible Spending

Account (HCFSA): If you are enrolled in this HDHP with a Health Savings Account

(HSA), and start or become covered by a HCFSA health care flexible spending account

(such as FSAFEDS offers – see Section 11), this HDHP cannot continue to contribute to

your HSA. Similarly, you cannot contribute to an HSA if your spouse enrolls in an

HCFSA. Instead, when you inform us of your coverage in an HCFSA, we will establish

an HRA for you.

Health Savings Accounts

(HSA)

If you aren’t eligible for an HSA, for example, you are enrolled in Medicare or have

another health plan, we will administer and provide an HRA instead. You must notify us

that you are ineligible for an HSA.

In 2013, we will give you an HRA credit of $1,000 per year for a Self Only enrollment

and $2,000 per year for a Self and Family enrollment. You can use funds in your HRA to

help pay your health plan deductible and/or for certain expenses that don’t count toward

the deductible.

HRA features include:

• For our HDHP option, the HRA is administered by.

Health Reimbursement

Arrangements (HRA)

61 2013 Coventry Health Plan of Florida Section 5 High Deductible Health Plan

• Entire HRA credit (prorated from your effective date to the end of the plan year) is

available from your effective date of enrollment.

• Tax-free credit can be used to pay for qualified medical expenses for you and any

individuals covered by this HDHP.

• Unused credits carryover from year to year.

• HRA credit does not earn interest.

• HRA credit is forfeited if you leave Federal employment or switch health insurance

plans.

• An HRA does not affect your ability to participate in an FSAFEDS Health Care

Flexible Spending Account (HCFSA). However, you must meet FSAFEDS eligibility

requirements.

When you use network providers, your annual maximum for out-of-pocket expenses

(deductibles, coinsurance and copayments) for covered services is limited to $5,000 per

person or $10,000 per family enrollment. However, certain expenses do not count toward

your out-of-pocket maximum and you must continue to pay these expenses once you

reach your out-of-pocket maximum (such as expenses in excess of the Plan’s allowable

amount or benefit maximum). Refer to Section 4 Your catastrophic protection out-of-

pocket maximum and HDHP Section 5

Traditional medical coverage subject to the

deductible

for more details.

Catastrophic protection

for out-of-pocket

expenses

HDHP Section 5(i) describes the health education resources and account management

tools available to you to help you manage your health care and your health care dollars.

Health education

resources and account

management tools

62 2013 Coventry Health Plan of Florida Section 5 High Deductible Health Plan

Section 5. Savings – HSAs and HRAs

Feature Comparison Health Savings Account (HSA) Health Reimbursement

Arrangement (HRA)

The Plan will establish an HSA for you with

Coventry Consumer Choice, this HDHP’s fiduciary

(an administrator, trustee or custodian as defined by

Federal tax code and approved by IRS.)

Health Equity

15 West Scenic Pointe Drive

Suite 400

Draper, UT 84020

Please refer to the number on your ID card

is the HRA fiduciary for this

Plan.

Administrator

Set-up fee is paid by the HDHP. None. Fees

You must:

• Enroll in this HDHP

• Have no other health insurance coverage (does

not apply to specific injury, accident, disability,

dental, vision or long-term care coverage)

• Not be enrolled in Medicare

• Not be claimed as a dependent on someone

else’s tax return

• Not have received VA benefits in the last three

months

• Complete and return all banking paperwork.

You must enroll in this HDHP.

Eligibility is determined on the

first day of the month following

your effective day of enrollment

and will be prorated for length of

enrollment.

Eligibility

If you are eligible for HSA contributions, a portion

of your monthly health plan premium is deposited to

your HSA each month. Premium pass through

contributions are based on the effective date of your

enrollment in the HDHP.

In addition, you may establish pre-tax HSA

deductions from your paycheck to fund your HSA

up to IRS limits using the same method that you use

to establish other deductions (i.e., Employee

Express, MyPay, etc.).

Eligibility for the annual credit

will be determined on the first

day of the month and will be

prorated for length of enrollment.

The entire amount of your HRA

will be available to you upon

your enrollment.

Funding

For 2013, a monthly premium pass through of

$83.34 will be made by the HDHP directly into your

HSA each month.

For 2013, your HRA annual

credit is $1,000 (prorated for

mid-year enrollment).

Self Only enrollment

For 2013, a monthly premium pass through of

$166.67 will be made by the HDHP directly into

your HSA each month.

For 2013, your HRA annual

credit is $2,000 (prorated for

mid-year enrollment).

Self and Family

enrollment

The full HRA credit will be

available, subject to proration, on

the effective date of enrollment.

The HRA does not earn interest.

Contributions/credits

63 2013 Coventry Health Plan of Florida Section 5 High Deductible Health Plan

The maximum that can be contributed to your HSA

is an annual combination of HDHP premium pass

through and enrollee contribution funds, which

when combined, do not exceed the maximum

contribution amount set by the IRS of $3,250 for an

individual and $6,450 for a family for a family.

If you enroll during Open Season, you are eligible to

fund your account up to the maximum contribution

limit set by the IRS. To determine the amount you

may contribute, subtract the amount the Plan will

contribute to your account for the year from the

maximum allowable contribution.

You are eligible to contribute up to the IRS limit for

partial year coverage as long as you maintain your

HDHP enrollment for 12 months following the last

month of the year of your first year of eligibility. To

determine the amount you may contribute, take the

IRS limit and subtract the amount the Plan will

contribute to your account for the year.

If you do not meet the 12 month requirement, the

maximum contribution amount is reduced by 1/12

for any month you were ineligible to contribute to

an HSA. If you exceed the maximum contribution

amount, a portion of your tax reduction is lost and a

10% penalty is imposed. There is an exception for

death or disability.

You may rollover funds you have in other HSAs to

this HDHP HSA (rollover funds do not affect your

annual maximum contribution under this HDHP).

HSAs earn tax-free interest (does not affect your

annual maximum contribution).

Catch-up contribution discussed on page 66.

You may make an annual maximum contribution of

$2,250.

You cannot contribute to the

HRA.

Self Only enrollment

You may make an annual maximum contribution of

$4,450.

You cannot contribute to the

HRA.

Self and Family

enrollment

You can access your HSA by the following methods:

• Debit card

• Withdrawal form

• Checks

For qualified medical expenses

under your HDHP, you will be

automatically reimbursed when

claims are submitted through the

HDHP. For expenses not covered

by the HDHP, such as

orthodontia, a reimbursement

form will be sent to you upon

your request.

Access funds

You can pay the out-of-pocket expenses for yourself,

your spouse or your dependents (even if they are not

covered by the HDHP) from the funds available in

your HSA. See IRS Publication 502 for a list of

eligible medical expenses.

You can pay the out-of-pocket

expenses for qualified medical

expenses for individuals covered

under the HDHP.

Distributions/

withdrawals

• Medical

64 2013 Coventry Health Plan of Florida Section 5 High Deductible Health Plan

Non-reimbursed qualified

medical expenses are allowable if

they occur after the effective date

of your enrollment in this Plan.

See

Availability of funds

below

for information on when funds

are available in the HRA.

See IRS Publication 502 for a list

of eligible medical expenses.

Physician prescribed over-the-

counter drugs and Medicare

premiums are also reimbursable.

Most other types of medical

insurance premiums are not

reimbursable.

If you are under age 65, withdrawal of funds for

non-medical expenses will create a 20% income tax

penalty in addition to any other income taxes you

may owe on the withdrawn funds.

When you turn age 65, distributions can be used for

any reason without being subject to the 20% penalty,

however they will be subject to ordinary income tax.

Not applicable – distributions

will not be made for anything

other than non-reimbursed

qualified medical expenses.

• Non-medical

Funds are not available for withdrawal until all the

following steps are completed:

• Your enrollment in this HDHP is effective

(effective date is determined by your agency in

accord with the event permitting the enrollment

change).

• The HDHP receives record of your enrollment

and initially establishes your HSA account with

the fiduciary by providing information it must

furnish and by contributing the minimum

amount required to establish an HSA.

The fiduciary sends you HSA paperwork for you to

complete and the fiduciary receives the completed

paperwork back from you

The entire amount of your HRA

will be available to you upon

your enrollment in the HDHP.

Funds are not available for

withdrawal until all the following

steps are completed:

• Your enrollment in this

HDHP is effective (effective

date is determined by your

agency in accord with the

event permitting the

enrollment change).

• The HDHP receives record of

your enrollment and initially

establishes your HSA account

with the fiduciary by

providing information it must

furnish and by contributing

the minimum amount

required to establish an HSA.

The fiduciary sends you HSA

paperwork for you to complete

and the fiduciary receives the

completed paperwork back from

you.

Availability of funds

FEHB enrollee HDHP Account owner

You can take this account with you when you

change plans, separate or retire.

Portable

65 2013 Coventry Health Plan of Florida Section 5 High Deductible Health Plan

If you do not enroll in another HDHP, you can no

longer contribute to your HSA. See page 63 for

HSA eligibility.

If you retire and remain in this

HDHP, you may continue to use

and accumulate credits in your

HRA.

If you terminate employment or

change health plans, only eligible

expenses incurred while covered

under the HDHP will be eligible

for reimbursement subject to

timely filing requirements.

Unused funds are forfeited.

Yes, accumulates without a maximum cap. Yes, accumulates without a

maximum cap.

Annual rollover

If you have an HSA

All contributions are aggregated and cannot exceed the maximum contribution amount set

by the IRS. You may contribute your own money to your account through payroll

deductions, or you may make lump sum contributions at any time, in any amount not to

exceed an annual maximum limit. If you contribute, you can claim the total amount you

contributed for the year as a tax deduction when you file your income taxes. Your own

HSA contributions are either tax-deductible or pre-tax (if made by payroll deduction).

You receive tax advantages in any case. To determine the amount you may contribute,

subtract the amount the Plan will contribute to your account for the year from the

maximum contribution amount set by the IRS. You have until April 15 of the following

year to make HSA contributions for the current year.

If you newly enroll in an HDHP during Open Season and your effective data is after

January 1st or you otherwise have partial year coverage, you are eligible to fund your

account up to the maximum contribution limit set by the IRS as long as you maintain your

HDHP enrollment for 12 months following the last month of the year of your first year of

eligibility. If you do not meet this requirement, a portion of your tax reduction is lost and

a 10% penalty is imposed. There is an exception for death or disability.

Contributions

If you are age 55 or older, the IRS permits you to make additional “catch-up”

contributions to your HSA. The allowable catch-up contribution is $1,000. Contributions

must stop once an individual is enrolled in Medicare. Additional details are available on

the U.S. Department of Treasury Web site at www.ustreas.gov/offices/public-affairs/hsa/ .

Catch-up contributions

If you do not have a named beneficiary, if you are married, it becomes your spouse’s

HSA; otherwise, it becomes part of your taxable estate.

If you die

You can pay for “qualified medical expenses,” as defined by IRS Code 213(d). These

expenses include, but are not limited to, medical plan deductibles, diagnostic services

covered by your plan, long-term care premiums, health insurance premiums if you are

receiving Federal unemployment compensation, physician prescribed over-the-counter

drugs, LASIK surgery, and some nursing services.

When you enroll in Medicare, you can use the account to pay Medicare premiums or to

purchase health insurance other than a Medigap policy. You may not, however, continue

to make contributions to your HSA once you are enrolled in Medicare.

For a detailed list of IRS-allowable expenses, request a copy of IRS Publication 502 by

calling 1-800-829-3676, or visit the IRS Web site at www.irs.gov and click on “Forms and

Publications.” Note: Although physician prescribed over-the-counter drugs are not listed

in the publication, they are reimbursable from your HSA. Also, insurance premiums are

reimbursable under limited circumstances.

Qualified expenses

66 2013 Coventry Health Plan of Florida Section 5 High Deductible Health Plan

You may withdraw money from your HSA for items other than qualified health expenses,

but it will be subject to income tax and if you are under 65 years old, an additional 20%

penalty tax on the amount withdrawn.

Non-qualified expenses

You will receive a periodic statement that shows the “premium pass through”,

withdrawals, and interest earned on your account. In addition, you will receive an

Explanation of Payment statement when you withdraw money from your HSA.

Tracking your HSA

balance

You can request reimbursement in any amount. However, funds will not be disbursed

until your reimbursement totals at least $25.

Minimum

reimbursements from

your HSA

If you have an HRA

If you don’t qualify for an HSA when you enroll in this HDHP, or later become ineligible

for an HSA, we will establish an HRA for you. If you are enrolled in Medicare, you are

ineligible for an HSA and we will establish an HRA for you. You must tell us if you

become ineligible to contribute to an HSA.

Why an HRA is

established

Please review the chart on page 63 which details the differences between an HRA and an

HSA. The major differences are:

• you cannot make contributions to an HRA

• funds are forfeited if you leave the HDHP

• an HRA does not earn interest

HRAs can only pay for qualified medical expenses, such as deductibles, copayments, and

coinsurance expenses, for individuals covered by the HDHP. FEHB law does not permit

qualified medical expenses to include services, drugs, or supplies related to abortions,

except when the life of the mother would be endangered if the fetus were carried to term,

or when the pregnancy is the result of an act of rape or incest.

How an HRA differs

67 2013 Coventry Health Plan of Florida Section 5 High Deductible Health Plan

Section 5. Preventive care

High Deductible Health Plan

Important things you should keep in mind about these benefits:

•Preventive care services listed in this Section are not subject to the deductible.

•You must use providers that are part of our network.

•For all other covered expenses, please see Section 5 –

Traditional medical coverage subject to the deductible

Benefit Description You Pay

Preventive care, adult

Routine screenings, such as:

• Blood tests

• Urinalysis

• Total Blood Cholesterol

• Routine Prostate Specific Antigen (PSA) test - one

annually for men age 50 and older

• Colorectal Cancer Screening , including:

- Fecal occult blood test yearly starting at age 50

- Sigmoidoscopy screening – every five years

starting at age 50

- Double contrast barium enema – every five

years starting at age 50

- Colonoscopy screening – every ten years starting

at age 50

• Routine annual digital rectal exam (DRE) for men

age 40 and older

Nothing

• Well woman - one annually; including, but not

limited to:

- Routine pap test

- Human papillomavirus testing for women age 30

and up once every three years

- Counseling for sexually transmitted infections

on an annual basis.

- Counseling and screening for human immune-

deficiency virus on an annual basis

- Contraceptive methods and counseling

- Screening and counseling for interpersonal and

domestic violence

Nothing

• Adult routine immunizations endorsed by the

Centers for Disease Control and Prevention (CDC):

Nothing

• Routine mammogram - covered for women age 35

and older, as follows:

- From age 35 through 39, one during this five

year period

Nothing

Preventive care, adult - continued on next page

68 2013 Coventry Health Plan of Florida Section 5 High Deductible Health Plan

High Deductible Health Plan

Benefit Description You Pay

Preventive care, adult (cont.)

- From age 40 through 64, one every calendar

year

- At age 65 and older, one every two consecutive

calendar years

Nothing

• Routine physicals which include:

- One exam every 24 months up to age 65

- One exam every 12 months age 65 and older

• Routine exams limited to:

- One routine eye exam every 12 months

- One routine OB/GYN exam every 12 months

including 1 Pap smear and related services

- One routine hearing exam every 24 months

Nothing

Not covered:

•

Physical exams required for obtaining or

continuing employment or insurance, attending

schools or camp, athletic exams or travel.

•

Immunizations, boosters, and medications for

travel or work-related exposure.

All charges

Preventive care, children

Professional services, such as:

• Well-child care charges for routine examinations,

immunizations and care (up to age 26)

• Childhood immunizations recommended by the

American Academy of Pediatrics

Examinations, such as:

• Eye exam through age 17 to determine the need for

vision correction

• Hearing exams through age 17 to determine the

need for hearing correction

Nothing

Not covered:

•

Physical exams required for obtaining or

continuing employment or insurance, attending

schools or camp, or travel.

•

Immunizations, boosters, and medications for

travel.

All charges

69 2013 Coventry Health Plan of Florida Section 5 High Deductible Health Plan

High Deductible Health Plan

Benefit Description You Pay

Dental Preventive Care

Preventive care limited to:

• Prophylaxis (cleaning of teeth) – limited to 2

treatments per calendar year

• Fluoride applications (limited to 1 treatment per

calendar year and for children under age 16)

• Sealants – (once every 3 years, from the last date

of service, on permanent molars for children under

age 16)

• Space maintainer (primary teeth only)

• Bitewing x-rays (one set per calendar year)

• Complete series x-rays (one complete series every

3 years)

• Periapical x-rays

• Routine oral evaluations (limited to 2 per calendar

year)

Nothing

70 2013 Coventry Health Plan of Florida Section 5 High Deductible Health Plan

Section 5. Traditional medical coverage subject to the deductible

High Deductible Health Plan

Important things you should keep in mind about these benefits:

•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable

only when we determine they are medically necessary.

•In-network preventive care is covered at 100% (see page 68) and is not subject to the calendar year deductible.

•The deductible is $2,500 per person or $5,000 per family enrollment. The family deductible can be satisfied by one or

more family members. The deductible applies to almost all benefits under Traditional medical coverage. You must pay

your deductible before your Traditional medical coverage may begin.

•Under Traditional medical coverage, you are responsible for your coinsurance and copayments for covered expenses.

•When you use network providers, you are protected by an annual catastrophic maximum on out-of-pocket expenses for

covered services. After your coinsurance, copayments and deductibles total $5,000 per person or $10,000 per family

enrollment in any calendar year, you do not have to pay any more for covered services from network providers. However,

certain expenses do not count toward your out-of-pocket maximum and you must continue to pay these expenses once you

reach your out-of-pocket maximum (such as expenses in excess of the Plan’s benefit maximum, or if you use out-of-

network providers, amounts in excess of the Plan allowance).

•In-network benefits apply only when you use a network provider. When a network provider is not available, out-of-

network benefits apply.

•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.

Benefits Header You Pay

Deductible before Traditional medical

coverage begins

The deductible applies to almost all benefits in this

Section. In the You pay column, we say “No

deductible” when it does not apply. When you

receive covered services from network providers, you

are responsible for paying the allowable charges until

you meet the deductible.

100% of allowable charges until you meet the deductible of

$2,500 per person or $5,000 per family enrollment

After you meet the deductible, we pay the allowable

charge (less your coinsurance or copayment) until

you meet the annual catastrophic out-of-pocket

maximum.

In-network: After you meet the deductible, you pay the indicated

coinsurance or copayments for covered services. You may choose

to pay the coinsurance and copayments from your HSA or HRA,

or you can pay for them out-of-pocket.

Out-of-network: After you meet the deductible, you pay the

indicated coinsurance based on our Plan allowance and any

difference between our allowance and the billed amount.

71 2013 Coventry Health Plan of Florida Section 5 High Deductible Health Plan

Section 5(a). Medical services and supplies provided by physicians and other health

care professionals

High Deductible Health Plan

Benefit Description You pay

Diagnostic and treatment services

Professional services of physicians

• In physician’s office

• Office medical consultations

• Second surgical opinion

• At home

After deductible, $10 per office visit to

your primary care physician; $25 per

office visit to a specialist

• In an urgent care center After deductible, $25 copay

• During a hospital stay

• In a skilled nursing facility

After deductible, 20% coinsurance

Lab, X-ray and other diagnostic tests

Tests, such as:

• Blood tests

• Urinalysis

• Non-routine Pap tests

• Pathology

• X-rays

• Non-routine mammograms

• CAT Scans/MRI

• Ultrasound

• Electrocardiogram and EEG

After deductible, 20% coinsurance

Maternity care

Complete maternity (obstetrical) care, such as:

• Prenatal care

• Delivery

• Postnatal care

After deductible, a one time $25 copay

• Screening for gestational diabetes for pregnant women between 24-28

weeks gestation or first prenatal visit for women at a high risk.

• Breastfeeding support, supplies and counseling for each birth

Nothing

Note: Here are some things to keep in mind:

• You do not need to precertify your normal delivery; see page 16 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.

Maternity care - continued on next page

72 2013 Coventry Health Plan of Florida Section 5(a) High Deductible Health Plan

High Deductible Health Plan

Benefit Description You pay

Maternity care (cont.)

• 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. Surgical benefits, not maternity benefits, apply to

circumcision.

• We pay hospitalization and surgeon services for non-maternity care the same

as for illness and injury.

Family planning

Contraceptive counseling on an annual basis Nothing

A range of voluntary family planning services, limited to:

• Surgically implanted contraceptives

• Injectable contraceptive drugs (such as Depo provera)

• Intrauterine devices (IUDs)

• Diaphragms

• Voluntary sterilization

Note: We cover oral contraceptives under the prescription drug benefit.

At hospital: After deductible, 20%

coinsurance

At freestanding facility: After deductible,

$200 copay

Not covered:

•

Reversal of voluntary surgical sterilization

•

Genetic counseling.

All Charges

Infertility services

Diagnosis and treatment of infertility such as:

• Artificial insemination:

• Intravaginal insemination (IVI)

• Intracervical insemination (ICI)

• Intrauterine insemination (IUI)

• Fertility drugs

Note: We cover Injectable fertility drugs under medical benefits and oral

fertility drugs under the prescription drug benefit.

After deductible, $25 copay

Not covered:

•

Assisted reproductive technology (ART) procedures, such as:

In vitro fertilization

Embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-

fallopian transfer (ZIFT)

•

Services and supplies related to ART procedures

•

Cost of donor sperm

•

Cost of donor egg

All charges

73 2013 Coventry Health Plan of Florida Section 5(a) High Deductible Health Plan

High Deductible Health Plan

Benefit Description You pay

Allergy care

• Testing and treatment

• Allergy injections

After deductible, $10 per office visit to

your primary care physician; $25 per

office visit to a specialist

• Allergy serum Nothing

Not covered: Proactive food testing and sublingual allergy desensitization All charges

Treatment therapies

• Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow

transplants is limited to those transplants listed under Organ/Tissue Transplants

on page 81.

• Respiratory and inhalation therapy

• Dialysis – hemodialysis and peritoneal dialysis

• Intravenous (IV)/Infusion Therapy – Home IV and antibiotic therapy

• Applied Behavior Analysis (ABA) Therapy for Autism Spectrum Disorder

• Growth hormone therapy (GHT)

Note: Growth hormone is covered under the prescription drug benefit.

Note: We only cover GHT when we preauthorize the treatment. We will ask

you to submit information that establishes that the GHT is medically necessary.

Ask us to authorize GHT before you begin treatment. We will only cover GHT

services and related services and supplies that we determine are medically

necessary. See

Other services under You need prior Plan approval for certain

services

on page 18.

After deductible, $10 per office visit to

your primary care physician; $25 per

office visit to a specialist

At hospital: After deductible, 20%

coinsurance

At freestanding facility: After deductible,

$25 copay

Not covered:

•

Chelation therapy

•

Any furniture, plumbing, electrical or other fixtures to perform dialysis at

home.

All charges

Physical and occupational therapies

60 visits per calendar year; no less than 2 consecutive months of therapy for

each condition for each of the following services:

• Qualified physical therapists

• Speech therapists

• Occupational therapists

Note: We only cover therapy to restore bodily function when there has been a

total or partial loss of bodily function due to illness or injury.

Cardiac rehabilitation following a heart transplant, bypass surgery or a

myocardial infarction is provided for up to 100 sessions.

At hospital: After deductible, 20%

coinsurance

At freestanding facility: After deductible,

$25 copay

Not covered:

•

Long-term rehabilitative therapy

•

Exercise programs

•

Pulmonary rehabilitation

All charges

74 2013 Coventry Health Plan of Florida Section 5(a) High Deductible Health Plan

High Deductible Health Plan

Benefit Description You pay

Speech therapy

60 visits per calendar year; no less than 2 consecutive months of therapy for

each condition.

At hospital: After deductible, 20%

coinsurance

At freestanding facility: After deductible,

$25 copay

Hearing services (testing, treatment, and supplies)

• 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

After deductible, $10 per office visit to

your primary care physician; $25 per

office visit to a specialist

At hospital: After deductible, 20%

coinsurance

At freestanding facility: After deductible,

$25 copay

• External hearing aids

• 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.

After deductible, $25 copay

Vision services (testing, treatment, and supplies)

• Annual eye refractions, including written lens prescription.

Note: see Preventive care, children for eye exams for children.

$19

Frames (one pair each calendar year from the Coventry Health Care of Florida

Standard collection at a participating provider)

Nothing

• One pair of frames to correct an impairment directly caused by accidental

ocular injury or intraocular (such as for cataracts)

Nothing

• Single vision lenses

• Bifocal lenses

• Trifocal lenses

$20

$25

$30

Contact Lenses

• Medically necessary contact lenses (evaluation and fitting) in lieu of

eyeglasses

• Daily wear contact lenses (Bausch & Lomb, Biomedics)

• Extended wear contact lenses (Bausch & Lomb)

• Disposable lenses (2 boxes of all clear spherical lens)

Nothing

$10

$15

$48

• All eyewear (including contact lenses) outside of the Standard Select plan

(preselected collection)

Retail cost minus 20% discount

Not covered:

•

Eye exercises and orthoptics

•

Radial keratotomy and other refractive surgery

All charges

75 2013 Coventry Health Plan of Florida Section 5(a) High Deductible Health Plan

High Deductible Health Plan

Benefit Description You pay

Foot care

Routine foot care when you are under active treatment for a metabolic or

peripheral vascular disease, such as diabetes.

After deductible, $25 per office 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

Orthopedic and prosthetic devices

• 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.

• External hearing aids

• 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.

Note: For information on the professional charges for the surgery to insert an

implant, see Section 5(b)

Surgical and anesthesia services.

For information on

the hospital and/or ambulatory surgery center benefits, see Section 5(c)

Services provided by a hospital or other facility, and ambulance services

After deductible, 20% coinsurance

Not covered:

•

Orthopedic and corrective shoes, arch supports, foot orthotics, heel pads and

heel cups

•

Lumbosacral supports

•

Corsets, trusses, elastic stockings, support hose, and other supportive

devices

•

Prosthetic replacements provided less than {3} years after the last one we

covered

All charges

Durable medical equipment (DME)

We cover rental or purchase of durable medical equipment, at our option,

including repair and adjustment. Covered items include:

• Oxygen

• Dialysis equipment

• Hospital beds

• Wheelchairs

• Crutches

• Walkers

• Audible prescription reading devices

After deductible, 20% coinsurance

Diabetes supplies: After deductible,

same as Rx Brand copay per month

Durable medical equipment (DME) - continued on next page

76 2013 Coventry Health Plan of Florida Section 5(a) High Deductible Health Plan

High Deductible Health Plan

Benefit Description You pay

Durable medical equipment (DME) (cont.)

• Speech generating devices

• Blood glucose monitors, test strips, lancet

• Insulin pumps

Note: Call us at 866-575-1882 as soon as your Plan physician prescribes this

equipment. We will arrange with a health care provider to rent or sell you

durable medical equipment at discounted rates and will tell you more about

this service when you call.

After deductible, 20% coinsurance

Diabetes supplies: After deductible,

same as Rx Brand copay per month

Not covered:

•

Motorized wheelchairs unless medically necessary to meet the minimum

functional requirements of the member

•

More than one device for the same body part or more than one piece of

equipment that serves the same function

•

Spare or alternate use devices

•

Adjust, repair or maintenance of devices which are worn or damaged as a

result of abuse

•

Replacement of lost devices

•

Exercise equipment and bicycles

•

Elevators and chair lifts, plus home and automobile modifications

•

Air conditioners, humidifiers, dehumidifiers, air purifiers, pillows,

whirlpools, spas, jacuzzis, and saunas

•

Any equipment that does not serve a medical purpose

All charges

Home health services

• Home health care ordered by a Plan physician and provided by a registered

nurse (R.N.), licensed practical nurse (L.P.N.), licensed vocational nurse (L.

V.N.), or home health aide.

• Services include oxygen therapy, intravenous therapy and medications.

After deductible, 20% coinsurance

Not covered:

•

Nursing care requested by, or for the convenience of, the patient or the

patient’s family.

•

Home care primarily for personal assistance that does not include a medical

component and is not diagnostic, therapeutic, or rehabilitative.

•

Services primarily for hygiene, feeding, exercising, moving the patient,

homemaking, companionship or giving oral medication.

All charges

Chiropractic

• Manipulation of the spine and extremities

• Adjunctive procedures such as ultrasound, electrical muscle stimulation,

vibratory therapy, and cold pack application

After deductible, $10 per office visit to

your primary care physician; $25 per

office visit to a specialist

Not covered:

All services not deemed medically necessary.

All charges

77 2013 Coventry Health Plan of Florida Section 5(a) High Deductible Health Plan

High Deductible Health Plan

Benefit Description You pay

Alternative treatments

Acupuncture – by a doctor of medicine or osteopathy for:

• anesthesia,

• pain relief

After deductible, $10 per office visit to

your primary care physician; $25 per

office visit to a specialist

Not covered:

•

Naturopathic services

•

Hypnotherapy

•

Biofeedback

All charges

Educational classes and programs

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

Nothing for counseling for up to two quit

attempts per year.

Nothing for OTC and prescription drugs

approved by the FDA to treat tobacco

dependence.

• Diabetes self managemen

• Childhood obesity education

Nothing

78 2013 Coventry Health Plan of Florida Section 5(a) High Deductible Health Plan

Section 5(b). Surgical and anesthesia services

provided by physicians and other health care professionals

High Deductible Health Plan

•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this

brochure and are payable only when we determine they are medically necessary.

•Plan physicians must provide or arrange your care.

•The deductible is $2,500 for Self Only enrollment and $5,000 for Self and Family enrollment each

calendar year. The Self and Family deductible can be satisfied by one or more family members.

The deductible applies to almost all benefits in this Section.

•After you have satisfied your deductible, your Traditional medical coverage begins.

•Under your Traditional medical coverage, you will be responsible for your coinsurance amounts or

copayments for eligible medical expenses and prescriptions.

•The amounts listed below are for the charges billed by a physician or other health care professional

for your surgical care. Look in Section 5(c) for charges associated with the facility (i.e. hospital,

surgical center, etc.).

•YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR SOME SURGICAL

PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure

which services require precertification and identify which surgeries require precertification.

Benefits Description You pay

Surgical procedures

A comprehensive range of services, such as:

• Operative procedures

• Treatment of fractures, including casting

• Normal pre- and post-operative care by the surgeon

• Correction of amblyopia and strabismus

• Endoscopy procedures

• Biopsy procedures

• Removal of tumors and cysts

• Correction of congenital anomalies (see

Reconstructive surgery

)

• Insertion of internal prosthetic devices . See 5(a)

Orthopedic and prosthetic

devices

for device coverage information

• Treatment of burns

Note: Generally, we pay for internal prostheses (devices) according to where

the procedure is done. For example, we pay Hospital benefits for a pacemaker

and Surgery benefits for insertion of the pacemaker.

At hospital: After deductible, 20%

coinsurance

At ambulatory surgical center: After

deductible, $50 copay

• Voluntary sterilization (e.g., tubal ligation, vasectomy) At hospital: After deductible, 20%

coinsurance

At freestanding facility: After deductible,

$200 copay

• Treatment of burns After deductible, $10 per office visit to

your primary care physician; $25 per

office visit to a specialist

Surgical treatment of morbid obesity (bariatric surgery) After deductible, $10 per office visit to

your primary care physician; $25 per

office visit to a specialist

Surgical procedures - continued on next page

79 2013 Coventry Health Plan of Florida Section 5(b) High Deductible Health Plan

High Deductible Health Plan

Benefits Description You pay

Surgical procedures (cont.)

Note: you must satisfy all of the following criteria in order for us to consider

the surgery:

• Body mass Index (BMI) of 40 or more or a BMI of 35 if co-morbidities

exist;

• 18 years old or have documentation of completion of Bone Growth;

• Failed attempted weight loss under the direction of MD or Presurgical

weight loss regime;

• Pre-operative psychological evaluation.

Note: Bariatric surgery requires our prior approval. See Services requiring our

prior approval on page 16.

After deductible, $10 per office visit to

your primary care physician; $25 per

office visit to a specialist

Not covered:

•

Reversal of voluntary sterilization

•

Routine treatment of conditions of the foot; see Foot care

All charges

Reconstructive surgery

• Surgery to correct a functional defect

• Surgery to correct a condition caused by injury or illness if:

• the condition produced a major effect on the member’s appearance and

• the condition can reasonably be expected to be corrected by such surgery

• Surgery to correct a condition that existed at or from birth and is a

significant deviation from the common form or norm. Examples of

congenital anomalies are: protruding ear deformities; cleft lip; cleft palate;

birthmarks; and webbed fingers and toes.

• All stages of breast reconstruction surgery following a mastectomy, such as:

• surgery to produce a symmetrical appearance of breasts;

• treatment of any physical complications, such as lymphedemas;

• breast prostheses and surgical bras and replacements (see Prosthetic devices)

Note: If you need a mastectomy, you may choose to have the procedure

performed on an inpatient basis and remain in the hospital up to 48 hours after

the procedure.

At hospital: After deductible, 20%

coinsurance

At ambulatory surgical center: After

deductible, $50 copay

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

80 2013 Coventry Health Plan of Florida Section 5(b) High Deductible Health Plan

High Deductible Health Plan

Benefits Description You pay

Oral and maxillofacial surgery

Oral surgical procedures, limited to:

• Reduction of fractures of the jaws or facial bones;

• Surgical correction of cleft lip, cleft palate or severe functional

malocclusion;

• Removal of stones from salivary ducts;

• Excision of leukoplakia or malignancies;

• Excision of cysts and incision of abscesses when done as independent

procedures; and

• Other surgical procedures that do not involve the teeth or their supporting

structures.

At hospital: After deductible, 20%

coinsurance

At ambulatory surgical center: After

deductible, $50 copay

Not covered:

•

Oral implants and transplants

•

Procedures that involve the teeth or their supporting structures (such as the

periodontal membrane, gingiva, and alveolar bone)

All charges

Organ/tissue transplants

These solid organ transplants are subject to medical 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 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 in ineffective.

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

HealthAmerica member approved for transplant services.

Solid organ transplants limited to:

• Cornea

• Heart

• Heart/lung

• Intestinal transplants

• Small intestine

• Small intestine with the liver

• Small intestine with multiple organs, such as the liver, stomach, and

pancreas

• Kidney

• Liver

• Lung: single/bilateral/lobar

• Pancreas

• Autologous pancreas islet cell transplant (as an adjunct to total or near total

pancreatectomy) only for patients with chronic pancreatitis

After deductible, 20% coinsurance

Organ/tissue transplants - continued on next page

81 2013 Coventry Health Plan of Florida Section 5(b) High Deductible Health Plan

High Deductible Health Plan

Benefits Description You pay

Organ/tissue transplants (cont.)

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)

After deductible, 20% coinsurance

These blood or marrow stem cell transplants are not subject to medical

necessity review by the Plan. Physicians measure many features of leukemia or

lymphoma cells to gain insight into its aggressiveness or likelihood of response

to various therapies. Some of these include the presence or absence of normal

and abnormal chromosomes, the extension of the disease throughout the body,

and how fast the tumor cells can grow. These analyses may allow physicians to

determine which diseases will respond to chemotherapy or which ones will not

respond to chemotherapy and may require a transplant.

Allogeneic (donor) transplants for:

• Acute lymphocytic or non-lymphocytic leukemia

• Advanced Hodgkin's lymphoma with reoccurrence (relapsed)

• Advanced non-Hodgkin's lymphoma with reoccurrence (relapsed)

• Acute myeloid leukemia

• Advanced Myeloproliferative Disorders (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)

• 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 immunodeficiency

• Severe or very severe aplastic anemia

• Sickle cell anemia

• X-linked lymphoproliferative syndrome

After deductible, 20% coinsurance

Organ/tissue transplants - continued on next page

82 2013 Coventry Health Plan of Florida Section 5(b) High Deductible Health Plan

High Deductible Health Plan

Benefits Description You pay

Organ/tissue transplants (cont.)

Autologous transplants for

• Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia

• Advanced Hodgkin’s lymphoma with reoccurrence (relapsed)

• Advanced non-Hodgkin’s lymphoma with reoccurrence (relapsed)

• Amyloidosis

• Breast Cancer

• Ependymoblastoma

• Epithelial ovarian cancer

• Ewing's sarcoma

• Multiple myeloma

• Medulloblastoma

• Pineoblastoma

• Neuroblastoma

• Testicular, Mediastinal, Retroperitoneal, and ovarian germ cell tumors

After deductible, 20% coinsurance

Mini-transplants performed in a clinical trial setting (non-myeloablative,

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 (i.e., myelogenous) leukemia

• Advanced Hodgkin’s lymphoma with reoccurrence (relapsed)

• Advanced non-Hodgkin’s lymphoma with reoccurrence (relapsed)

• Acute myeloid leukemia

• Advanced Myeloproliferative Disorders (MPDs)

• Amyloidosis

• Chronic lymphocytic leukemia/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 immunodeficiency

• Severe or very severe aplastic anemia

Autologous transplants for

• Acute lymphocytic or nonlymphocytic (i.e., myelogenous) leukemia

• Advanced Hodgkin’s lymphoma with reoccurrence (relapsed)

• Advanced non-Hodgkin’s lymphoma with reoccurrence (relapsed)

• Amyloidosis

• Neuroblastoma

After deductible, 20% coinsurance

Organ/tissue transplants - continued on next page

83 2013 Coventry Health Plan of Florida Section 5(b) High Deductible Health Plan

High Deductible Health Plan

Benefits Description You pay

Organ/tissue transplants (cont.)

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.

• Allogeneic transplants for

- Advanced Hodgkin’s lymphoma

- Advanced non-Hodgkin’s lymphoma

- Beta Thalassemia Major

- Chronic inflammatory demyelination polyneuropathy (CIDP)

- Early stage (indolent or non-advanced) small cell lymphocytic lymphoma

- Multiple myeloma

- Multiple sclerosis

- Sickle Cell anemia

• Mini-transplants (non-myeloablative allogeneic, reduced intensity

conditioning or RIC) for

- Acute lymphocytic or non-lymphocytic (i.e., myelogenous) 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 disorders (MDDs)

- Myelodysplasia/Myelodysplastic Syndromes

- Non-small cell lung cancer

- Ovarian cancer

- Prostate cancer

- Renal cell carcinoma

- Sarcomas

- Sickle cell anemia

• Autologous Transplants for

- Advanced Childhood kidney cancers

After deductible, 20% coinsurance

Organ/tissue transplants - continued on next page

84 2013 Coventry Health Plan of Florida Section 5(b) High Deductible Health Plan

High Deductible Health Plan

Benefits Description You pay

Organ/tissue transplants (cont.)

- Advanced Ewing sarcoma

- Advanced Hodgkin’s lymphoma

- Advanced non-Hodgkin’s lymphoma

- Breast Cancer

- Childhood rhabdomyosarcoma

- Chronic myelogenous leukemia

- Chronic lymphocytic lymphoma/small lymphocytic lymphoma (CLL/

SLL)

- Early stage (indolent or non-advanced) small cell lymphocytic lymphoma

- Epithelial Ovarian Cancer

- Mantle Cell (Non-Hodgkin lymphoma)

- Multiple sclerosis

- Small cell lung cancer

- Systemic lupus erythematosus

- Systemic sclerosis

After deductible, 20% coinsurance

Coventry Transplant Network (CTN) -

NOTE: We cover related medical and hospital expenses of the donor when we

cover the recipient. We cover donor screening tests and donor search expenses

for the actual solid organ or up to four bone marrow/stem cell transplant

donors in addition to the testing of family members.

Not covered:

•

Donor screening tests and donor search expenses, except as those shown

above

•

Donor expenses related to donating organs or tissue to a non-member

recipient

•

Implants of artificial organs

•

Transplants not specifically listed as covered

All charges

Anesthesia

Professional services provided in –

• Hospital (inpatient)

• Hospital outpatient department

• Skilled nursing facility

After deductible, 20% coinsurance

Professional services provided in -

• Office

After deductible, $50 copay

85 2013 Coventry Health Plan of Florida Section 5(b) High Deductible Health Plan

Section 5(c). Services provided by a hospital or other facility,

and ambulance services

High Deductible Health Plan

Important things you should keep in mind about these benefits:

•Please remember that all benefits are subject to the definitions , limitations, and exclusions in this

brochure and are payable only when we determine they are medically necessary .

•Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.

•The deductible is $2,500 for Self Only enrollment and $5,000 for Self and Family enrollment each

calendar year. The Self and Family deductible can be satisfied by one or more family members.

The deductible applies to all benefits in this Section.

•After you have satisfied your deductible, your Traditional medical coverage begins.

•Under your Traditional medical coverage, you will be responsible for your coinsurance amounts or

copayments for eligible medical expenses and prescriptions.

•Be sure to read Section 4,

Your costs for covered services

for valuable information about how cost-

sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with

Medicare.

•The amounts listed below are for the charges billed by the facility (i.e., hospital or surgical center)

or ambulance service for your surgery or care. Any costs associated with the professional charge (i.

e., physicians, etc.) are in Sections 5(a) or (b).

•YOUR PHYSICIAN MUST GET PRECERTIFICATION FOR HOSPITAL STAYS. Please

refer to Section 3 to be sure which services require precertification.

Benefit Description You pay

Inpatient hospital

Room and board, such as

• Ward, semiprivate, or intensive care accommodations;

• General nursing care

• Meals and special diets

Note: If you want a private room when it is not medically necessary, you pay

the additional charge above the semiprivate room rate.

After deductible, 20% 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

• Blood or blood plasma, if not donated or replaced

• Dressings , splints , casts , and sterile tray services

• Medical supplies and equipment, including oxygen

• Anesthetics, including nurse anesthetist services

• Take-home items

• Medical supplies, appliances, medical equipment, and any covered items

billed by a hospital for use at home (Note: calendar year deductible applies.)

After deductible, 20% coinsurance

Not covered:

•

Custodial care

•

Non-covered facilities, such as nursing homes, schools

All charges

Inpatient hospital - continued on next page

86 2013 Coventry Health Plan of Florida Section 5(c) High Deductible Health Plan

High Deductible Health Plan

Benefit Description You pay

Inpatient hospital (cont.)

•

Personal comfort items, such as telephone, television, barber services, guest

meals and beds

•

Private nursing care

All charges

Outpatient hospital or ambulatory surgical center

• Operating, recovery, and other treatment rooms

• Prescribed drugs and medicines

• Diagnostic laboratory tests, X-rays , and pathology services

• Administration of blood, blood plasma, and other biologicals

• Pre-surgical testing

• Dressings, casts , and sterile tray services

• Medical supplies, including oxygen

• Anesthetics and anesthesia service

Note: We cover hospital services and supplies related to dental procedures

when necessitated by a non-dental physical impairment. We do not cover the

dental procedures.

At hospital: After deductible, 20%

coinsurance

At ambulatory surgical center: After

deductible, $50 copay

Not covered: Blood and blood derivatives not replaced by the member All charges

Extended care benefits/Skilled nursing care facility benefits

The plan provides a comprehensive range of benefits for up to 100 days per

calendar year when you are hospitalized under the care of a Plan physician. All

medically necessary services are covered.

• Bed, board and general nursing care

• Drugs, biological, supplies and equipment ordinarily provided or arranged

by the skilled nursing facility when prescribed by a Plan physician.

After deductible, 20% coinsurance

Not covered: Custodial care All charges

Hospice care

Hospice care: up to 210 days per lifetime

The Plan covers supportive and palliative care for a terminally ill member.

Coverage is provided in the home or a hospice facility. Services include

inpatient, outpatient care and family counseling; these services are provided

under the direction of a Plan physician who certifies that the patient is in

terminal stages of illness, with a life expectancy of approximately six months

or less.

After deductible, 20% coinsurance

Not covered: Independent nursing, homemaker services All charges

Ambulance

• Local professional ambulance service when medically appropriate

• Air Ambulance limited to situation where ground transportation is not

medically appropriate – prior plan authorization required.

Note: See 5(d) for non-emergency service.

After deductible, no copay

87 2013 Coventry Health Plan of Florida Section 5(c) High Deductible Health Plan

Section 5(d). Emergency services/accidents

High Deductible Health Plan

Important things you should keep in mind about these benefits:

•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this

brochure and are payable only when we determine they are medically necessary.

•The deductible is $2,500 for Self Only enrollment and $5,000 for Self and Family enrollment each

calendar year. The Self and Family deductible can be satisfied by one or more family members.

The deductible applies to all benefits in this Section.

•After you have satisfied your deductible, your Traditional medical coverage begins.

•Under your Traditional medical coverage, you will be responsible for your coinsurance amounts and

copayments for eligible medical expenses and prescriptions.

•Be sure to read Section 4,

Your costs for covered services,

for valuable information about how cost-

sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with

Medicare.

What is a medical emergency?

A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe endangers your life or

could result in serious injury or disability, and requires immediate medical or surgical care. Some problems are emergencies

because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are

emergencies because they are potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or

sudden inability to breathe. There are many other acute conditions that we may determine are medical emergencies – what

they all have in common is the need for quick action.

What to do in case of emergency:

If you are in an emergency situation, please call your primary doctor. In extreme emergencies, if you are unable to contact

your doctor, 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. You or a family

member should notify the Plan within 48 hours unless it is not reasonably possible to do so. It is your responsibility to ensure

that the Plan has been notified timely.

If you need to be hospitalized, the Plan must be notified within 48 hours or the first working day following your admission,

unless it is not reasonably possible to notify the Plan in 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

ambulance charges covered in full.

Emergencies within our service area: Benefits are available for care from non-Plan provider in a medical emergency only

if delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition.

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 service that is immediately

required because of injury or unforeseen illness.

If you need to be hospitalized, the Plan must be notified within 48 or on the first working day following your admission,

unless it was not reasonably possible to notify the Plan in 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.

88 2013 Coventry Health Plan of Florida Section 5(d) High Deductible Health Plan

High Deductible Health Plan

Benefit Description You pay

Emergency within our service area

• Emergency care at a doctor’s office After deductible, $10 per office visit to

your primary care physician or $25 per

office visit to a specialist

• Emergency care at an urgent care center After deductible, $25 copay

• Emergency care as an outpatient in a hospital, including doctors’ services

Note: We waive the ER copay if you are admitted to the hospital

After deductible, $50 copay

Not covered: Elective care or non-emergency care All charges

Emergency outside our service area

• Emergency care at a doctor's office After deductible, $10 per office visit to

your primary care physician or $25 per

office visit to a specialist

• Emergency care at an urgent care center After deductible, $25 copay

• Emergency care as an outpatient in a hospital, including doctors’ services

Note: We waive the ER copay if you are admitted to the hospital.

After deductible, $50 copay

Not covered:

•

Elective care or non-emergency care and follow-up care recommended by

non-Plan providers that has not been approved by the Plan or provided by

Plan providers

•

Emergency care provided outside the service area if the need for care could

have been foreseen before leaving the service area

•

Medical and hospital costs resulting from a normal full-term delivery of a

baby outside the service area

All charges

Ambulance

• Professional ambulance service when medically appropriate.

• Air Ambulance limited to situation where ground transportation is not

medically appropriate – prior plan authorization required.

Note: See 5(d) for non-emergency service.

After deductible, no copay

89 2013 Coventry Health Plan of Florida Section 5(d) High Deductible Health Plan

Section 5(e). Mental health and substance abuse benefits

High Deductible Health Plan

You need to get Plan approval (preauthorization) for services and follow a treatment plan we approve in order to get benefits.

When you receive services as part of an approved treatment plan, cost-sharing and limitations for Plan mental health and

substance abuse benefits are no greater than for similar benefits for other illnesses and conditions.

Important things you should keep in mind about these benefits:

•Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable

only when we determine they are medically necessary.

•The calendar year deductible or, for facility care, the inpatient deductible applies to almost all benefits in this Section. We

added “(No deductible)” to show when a deductible does not apply.

•Be sure to read Section 4,

Your costs for covered services

, for valuable information about how cost-sharing works. Also,

read Section 9 about coordinating benefits with other coverage, including with Medicare.

•YOU MUST GET PREAUTHORIZATION FOR THESE SERVICES. Benefits are payable only when we determine

the care is clinically appropriate to treat your condition and only when you receive the care as part of a treatment plan that

we approve. The treatment plan may include services, drugs, and supplies described elsewhere in this brochure. To be

eligible to receive full benefits, you must follow the preauthorization process and get Plan approval of your treatment plan:

•We will provide medical review criteria or reasons for treatment plan denials to enrollees, members or providers upon

request or as otherwise required.

•OPM will base its review of disputes about treatment plans on the treatment plan’s clinical appropriateness. OPM will

generally not order us to pay or provide one clinically appropriate treatment plan in favor of another.

Benefit Description You pay

Professional services

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.

Your cost-sharing responsibilities are no

greater than for other illnesses or

conditions

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

• Professional charges for intensive outpatient treatment in a provider’s office

or other professional setting

• Electroconvulsive therapy

After deductible, $25 copay

90 2013 Coventry Health Plan of Florida Section 5(e) High Deductible Health Plan

High Deductible Health Plan

Benefit Description You pay

Diagnostics

• Outpatient diagnostic tests provided and billed by a licensed mental health

and substance abuse practitioner

• Outpatient diagnostic tests provided and billed by a laboratory, hospital or

other covered facility

• Inpatient diagnostic tests provided and billed by a hospital or other covered

facility

After deductible, $25 copay

Inpatient hospital or other covered facility

Inpatient services provided and billed by a hospital or other covered facility

• Room and board, such as semiprivate or intensive accommodations, general

nursing care, meals and special diets, and other hospital services

After deductible, 20% coinsurance

Not covered

Services that are not part of a preauthorized approved treatment plan.

Note: 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.

All charges

To be eligible to receive these benefits you must obtain a treatment plan and follow all of

the following network authorization processes:

Prior to seeking mental health and substance abuse treatment, you must call Psych/Care at

1-800-221-5487. Psych/Care is a managed behavioral health care firm with over 500

providers in our service area. You do not need a referral from your primary care physician

or authorization from us. A Psych/Care provider will evaluate you and develop a treatment

plan.

Once the treatment plan has been approved, you must follow it. If you need inpatient care,

your Psych/Care provider will arrange it for you. Call Psych/Care for a list of participating

providers in your area.

Preauthorization

We may limit your benefits if you do not obtain a treatment plan. Limitation

91 2013 Coventry Health Plan of Florida Section 5(e) High Deductible Health Plan

Section 5(f). Prescription drug benefits

High Deductible Health Plan

Here are some important things to keep in mind about these benefits:

•We cover prescribed drugs and medications, as described in the chart beginning on the next page.

•Please remember that all benefits are subject to the definitions, limitations and exclusions in this

brochure and are payable only when we determine they are medically necessary.

•The deductible is $2,500 for Self Only enrollment and $5,000 for Self and Family enrollment each

calendar year. The Self and Family deductible can be satisfied by one or more family members.

The deductible applies to all benefits in this Section.

•After you have satisfied your deductible, your Traditional medical coverage begins.

•Under your Traditional medical coverage, you will be responsible for your coinsurance amounts for

eligible medical expenses or copayments for eligible prescriptions.

•Be sure to read Section 4,

Your costs for covered services,

for valuable information about how cost-

sharing works. Also, read Section 9 about coordinating benefits with other coverage, including with

Medicare.

There are important features you should be aware of. These include:

•Who can write your prescription. A licensed plan physician or licensed dentist must write the prescription.

•Where you can obtain them. You may fill the prescription at a participating pharmacy. Please see the complete listing of

participating pharmacies in our provider directory.

•We use a formulary. The formulary is a list of medications, both brand and generic, that we approve as covered

medication. Plan pharmacies dispense prescription medication to our members based on our formulary list. However, we

cover non-formulary drugs prescribed by a Plan doctor. You must pay a higher copay for non-formulary drugs. Our

formulary has 4 tiers of prescription drug coverage. Tier 1 includes low cost generic formulary drugs. Tier 2 includes brand

name formulary drugs. Tier 3 includes high cost, mostly brand name non-formulary drugs that usually have generic or

brand name alternatives in Tiers 1 or 2. Tier 4 includes high technology and self-administered drugs, including growth

hormone. Tier 4 drugs require our prior authorization. If you’d like a copy of our formulary, please call us at

1-866-575-1882.

•These are the dispensing limitations. You may obtain a 30-day supply at a Plan pharmacy or a 90-day supply via mail