GHI Health Plan

www.EMBLEMHEALTH.com

877-VIA-EMBLEM (877-842-3625)

2018

A Prepaid Comprehensive Medical Plan.

IMPORTANT

• Rates: Back Cover

• Changes for 2018: Page 15

• Summary of benefits: Page 86

This plan's health coverage qualifies as minimum essential

coverage and meets the minimum value standard for the benefits it

provides. See page 4 for details. This plan is accredited. See page

14.

High Option Plan Serving: All of New York and Northern New

Jersey

Standard Option Plan Serving: New York City plus most New York

Counties, and Northern New Jersey

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

geographic service area to enroll. See page 14 for requirements.

Enrollment codes for this Plan:

801 High Option – Self Only

802 High Option – Self and Family

803 High Option - Self Plus One

804 Standard Option – Self Only

805 Standard Option – Self and Family

806 Standard Option - Self Plus One

RI 73-007

Important Notice from the GHI Health Plan About

Our Prescription Drug Coverage and Medicare

OPM has determined that the GHI Health Plan's prescription drug coverage is, on average, expected to pay out as much as

the standard Medicare prescription drug coverage will pay for all plan participants and is considered Creditable Coverage.

This means you do not need to enroll in Medicare Part D and pay extra for prescription drug coverage. If you decide to

enroll in Medicare Part D later, you will not have to pay a penalty for late enrollment as long as you keep your FEHB

coverage.

However, if you choose to enroll in Medicare Part D, you can keep your FEHB coverage and 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 at least as good

as Medicare’s prescription drug coverage, your monthly Medicare Part D premium will go up at least 1% per month for every

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

coverage, your premium will always be at least 19 percent higher than what many other people pay. You will have to pay

this higher premium as long as you have Medicare prescription drug coverage. In addition, you may have to wait until the

next Annual Coordinated Election Period (October 15 thru 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 800-772-1213 (TTY 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 800-MEDICARE (800-633-4227),; (TTY 877-486-2048).

Table of Contents

Cover Page ....................................................................................................................................................................................1

Important Notice ...........................................................................................................................................................................1

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

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

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

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

Discrimination is Against the Law ................................................................................................................................................5

Preventing Medical Mistakes ........................................................................................................................................................5

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

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

Minimum essential coverage (MEC) ..................................................................................................................................7

Minimum value standard ....................................................................................................................................................7

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

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

Family member coverage ....................................................................................................................................................8

Children’s Equity Act ..........................................................................................................................................................9

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

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

When FEHB coverage ends ..............................................................................................................................................10

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

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

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

Health Insurance Marketplace ...........................................................................................................................................11

Section 1. How this plan works ..................................................................................................................................................12

Section 2. Changes for 2018 .......................................................................................................................................................15

Section 3. How you get care .......................................................................................................................................................16

Identification cards ............................................................................................................................................................16

Where you get covered care ..............................................................................................................................................16

What you must do to get covered care ..............................................................................................................................16

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

Concurrent care claims ......................................................................................................................................................19

Emergency inpatient admission ..............................................................................................................................20

Maternity care .........................................................................................................................................................20

If you disagree with our pre-service claim decision .........................................................................................................20

To file an appeal with OPM ....................................................................................................................................21

Section 4. Your costs for covered services ..................................................................................................................................22

Cost-sharing ......................................................................................................................................................................22

Copayments .......................................................................................................................................................................22

Deductible .........................................................................................................................................................................22

Coinsurance .......................................................................................................................................................................22

Differences between our Plan allowance and the bill .......................................................................................................22

Your catastrophic protection out-of-pocket maximum .....................................................................................................23

Section 5. Benefits ......................................................................................................................................................................24

Section 5. High and Standard Option Benefits Overview ..........................................................................................................26

Section 5(a). Medical services and supplies provided by physicians and other health care professionals .................................27

Section 5(b). Surgical and anesthesia services provided by physicians and other health care professionals .............................41

1 2018 GHI Health Plan 2018 GHI Health Plan Table of Contents

Section 5(c). Services provided by a hospital or other facility, and ambulance services ...........................................................49

Section 5(d). Emergency services/accidents ...............................................................................................................................52

Section 5(e). Mental health and substance misuse disorder benefits ..........................................................................................54

Section 5(f). Prescription drug benefits ......................................................................................................................................56

Section 5(g). Dental benefits .......................................................................................................................................................60

Section 5(h). Wellness and Other Special Features .....................................................................................................................62

Section 5(i). High Option Point of Service benefits ...................................................................................................................63

Non-FEHB benefits available to Plan members .........................................................................................................................65

Section 6. General exclusions – services, drugs and supplies we do not cover ..........................................................................66

Section 7. Filing a claim for covered services ............................................................................................................................67

Section 8. The disputed claims process .......................................................................................................................................69

Section 9. Coordinating benefits with Medicare and other coverage .........................................................................................72

When you have other health coverage ..............................................................................................................................72

TRICARE and CHAMPVA ..............................................................................................................................................72

Workers’ Compensation ....................................................................................................................................................72

Medicaid ............................................................................................................................................................................72

When you have Federal Employees Dental and Vision Insurance Plan (FEDVIP) coverage ..........................................73

When you have Medicare .................................................................................................................................................73

What is Medicare? ..................................................................................................................................................73

The Original Medicare Plan (Part A or Part B) .................................................................................................................75

Section 10. Definitions of terms we use in this brochure ...........................................................................................................79

Section 11. Other Federal Programs ...........................................................................................................................................82

Important information about four Federal programs that complement the FEHB Program .............................................82

What is an FSA? ...............................................................................................................................................................82

Where can I get more information about FSAFEDS? ......................................................................................................83

Dental Insurance ...............................................................................................................................................................83

Vision Insurance ................................................................................................................................................................83

Index ............................................................................................................................................................................................85

Summary of benefits for the High Option of the GHI Health Plan - 2018 .................................................................................86

Summary of benefits for the Standard Option of the GHI Health Plan - 2018 ...........................................................................87

2018 Rate Information for GHI Health Plan ...............................................................................................................................89

2 2018 GHI Health Plan 2018 GHI Health Plan Table of Contents

Introduction

This brochure describes the benefits of Group Health Incorporated (GHI) under our contract (CS 1056) with the United

States Office of Personnel Management (OPM), as authorized by the Federal Employees Health Benefits law. Customer

service may be reached at (877) 842-3625 (4444) or through our website: www.emblemhealth.com. The address for GHI

administrative offices is:

Group Health Incorporated

55 Water St.

New York, NY 10041

This brochure is the official statement of benefits. No verbal 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. If you are enrolled in Self Plus One coverage,

you and one eligible family member that you designate when you enroll are entitled to these benefits. You do not have a

right to benefits that were available before January 1, 2018, unless those benefits are shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2018, and changes are

summarized beginning on page 16. Rates are shown at the end of this brochure.

Coverage under this plan qualifies as minimum essential coverage (MEC) and satisfies the Patient Protection and Affordable

Care Act's (ACA) individual share responsibility requirement. Please visit the Internal Revenue Service (IRS) website at

www.irs.gov/uac/Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more information on the

individual requirement for MEC.

The ACA establishes a minimum value for the standard of benefits of a health plan. The minimum standard is 60% (actuarial

value). The health coverage of this plan does meet the minimum value standard for the benefits the plan provides.

Plain Language

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

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

"we" means GHI Health Plan

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

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

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

Stop Health Care Fraud!

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

premium.

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

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

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

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

3 2018 GHI Health Plan Introduction/Plain Language/Advisory

•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.

•If the provider does not resolve the matter, call us at (877) 842-3625 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/our-inspector-general/hotline-to-report-fraud-waste-or-abuse/complaint-form/

The online reporting form is the desired method of reporting fraud in order to ensure accuracy, and a quicker

response time.

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 (TCC).

•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 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.

4 2018 GHI Health Plan Introduction/Plain Language/Advisory

Discrimination is Against the Law

GHI complies with applicable Federal civil rights laws, to include both Title VII of the Civil Rights Act of 1964 and Section

1557 of the Affordable Care Act. Pursuant to Section1557, GHI does not discriminate, exclude people, or treat them

differently on the basis of race, color, national origin, age disability, or sex.

Preventing Medical Mistakes

Medical mistakes continue to be a significant cause of preventable deaths within the United States. 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. Medical mistakes and their consequences also add significantly to the overall cost

of healthcare. Hospitals and healthcare providers are being held accountable for the quality of care and reduction in medical

mistakes by their accrediting bodies. You can also improve the quality and safety of your own health care and that of your

family members by learning more about and understanding your risks. 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 take notes, ask questions and understand answers.

2. Keep and bring a list of all the medicines you take.

•Bring the actual medicines or give your doctor and pharmacist a list of all the medicines and dosage that you take,

including non-prescription (over-the-counter) medicines and nutritional supplements.

•Tell your doctor and pharmacist about any drug, food, and other allergies you have, such as latex.

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

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.

•Understand both the generic and brand names of your medication. This helps ensure you do not receive double dosing

from taking both a generic and a brand. It also helps prevent you from taking a medication to which you are allergic.

3. Get the results of any test or procedure.

•Ask when and how you will get the results of test or procedures. Will it be in person, by phone, mail, through the Plan or

Provider's portal?

•Don’t assume the results are fine if you do not get them when expected. Contact your healthcare provider and ask for your

results.

•Ask what the results mean for your care.

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

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

hospital or clinic 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 or clinic.

5 2018 GHI Health Plan Introduction/Plain Language/Advisory

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 or

nutritional supplements you are taking.

Patient Safety Links

For more information on patient safety, please visit:

- www.jointcommission.org/speakup.aspx. The Joint Commission's Speak UP patient safety program.

- www.jointcommission.org/topics/patient_safety.aspx The Joint Commission helps health care organizations to improve

the quality and safety of the care they deliver.

- www.ahrq.gov/patients-consumers/ The Agency for Healthcare Research and Quality provides information about

patient safety, choosing quality health care providers, and improving the quality of care you receive.

- www.npsf.org . The National Patient Safety Foundation has information on how to ensure safer healthcare for you and

your family.

- www.bemedwise.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 healthcare professionals

working to improve patient safety.

Preventable Healthcare Acquired Conditions ("Never Event")

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. Errors in medical care that are clearly identifiable, preventable and serious in their consequences for

patients, can indicate a significant problem in the safety and credibility of a health care facility. These conditions and errors

are sometimes called "Never Events" or "Serious Reportable Events."

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. When such an event

occurs, neither you nor your FEHB plan will incur costs to correct the medical error.

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

services needed to correct Never Events, if you use GHI providers. This policy helps to protect you from preventable

medical errors and improve the quality of care you receive.

6 2018 GHI Health Plan Introduction/Plain Language/Advisory

FEHB Facts

Coverage information

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

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

• No pre-existing

condition limitation

Coverage under this plan qualifies as minimum essential coverage (MEC) and satisfies the

Patient Protection and Affordable Care Act’s (ACA) individual shared responsibility

requirement. Please visit the Internal Revenue Service (IRS) website at www.irs.gov/uac/

Questions-and-Answers-on-the-Individual-Shared-Responsibility-Provision for more

information on the individual requirement for MEC.

• Minimum essential

coverage (MEC)

Our health coverage meets the minimum value standard of 60% established by the ACA.

This means that we provide benefits to cover at least 60% of the total allowed costs of

essential health benefits. The 60% standard is an actuarial value; your specificout-of-

pocket costs are determined as explained in this brochure.

• Minimum value

standard

See www.opm.gov/healthcare-insurance/healthcare for enrollment information as well as:

• Information on the FEHB Program and plans available to you

• A health plan comparison tool

• A list of agencies that participate in Employee Express

• A link to Employee Express

• Information on and links to other electronic enrollment systems

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

you 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; and

• 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 Plus One coverage is an enrollment that covers

you and one eligible family members. Self and Family coverage is for you, your spouse,

and your dependent children under age 26, including any foster children authorized for

coverage by your employing agency or retirement office. Under certain circumstances,

you may also continue coverage for a disabled child 26 years of age or older who is

incapable of self-support.

If you have a Self Only enrollment, you may change to a Self and Family or Self Plus One

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 60 days is established by 5

CFR 890.301(e)(1)

• Types of coverage

available for you and

your family

7 2018 GHI Health Plan FEHB Facts

The Self Plus One or 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 Plus One or 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 are married.

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

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

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

child reaches age 26.

If you or one of your family members is enrolled in one FEHB plan, that person may

not be enrolled in or covered as a family member by another FEHB plan.

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

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

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

QLEs, visit the FEHB website at www.opm.gov/healthcare-insurance//lifeevents. If you

need assistance, please contact your employing agency, Tribal Benefits Officer, personnel/

payroll office, or retirement office.

Family members covered under your Self and Family enrollment are your spouse

(including a valid common law marriage and same sex domestic partners) and children as

described in the chart below. A Self Plus One enrollment covers you and your spouse, or

one other eligible family member as described in the chart below.

ChildrenCoverage

Natural children, 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 26th 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 you

human resources office or retirement system

for additional information.

Children incapable of self-support Children who are incapable of self-support

because of a mental or physical disability

that began before age 26 are eligible to

continue coverage. Contact your human

resources office or retirement system for

additional information.

Married children Married children (but NOT their spouse or

their own children) are covered until their

26th birthday.

Children with or eligible for employer-

provided health insurance

Children who are eligible for or have their

own employer-provided health insurance are

covered until their 26th birthday.

Newborns of covered children are insured only for routine nursery care during the covered

portion of the mother's maternity stay.

You can find additional information at www.opm.gov/healthcare-insurance.

• Family member

coverage

8 2018 GHI Health Plan FEHB Facts

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

2000. This law mandates that you be enrolled for Self Plus One or 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 in Self Plus One or 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 Plus

One or Self and Family coverage, as appropriate, 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 Plus One or Self and Family, as appropriate, in the same option of the same

plan; or

• If you are enrolled in an HMO that does not serve the area where the children live,

your employing office will change your enrollment to Self Plus One or Self and

Family, as appropriate, 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. Similarly, you cannot change to Self Plus One

if the court/administrative order identifies more than one child. Contact your employing

office for further information.

• Children’s Equity Act

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 2018 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 2017 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

9 2018 GHI Health Plan FEHB Facts

When you lose benefits

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

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

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

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

or other institution for care or treatment on the 31

day of the temporary extension is

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

confinement but not beyond the 60

day after the end of the 31 day temporary extension.

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

(TCC).

When FEHB coverage

ends

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

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

ordered your former spouse to provide health coverage 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 additional

information about your coverage choices. You can also visit OPM’s website at www.opm.

gov/healthcare-insurance/healthcare/plan-information/guides.

Upon divorce

If you leave Federal service, Tribal employment or if you lose coverage because you no

longer qualify as a family member, you may be eligible for Temporary Continuation of

Coverage (TCC). The Patient Protection and Affordable Care Act (ACA) did not

eliminate TCC or change the TCC rules. For example, you can receive TCC if you are not

able to continue your FEHB enrollment after you retire, if you lose your Federal or Tribal

job, if you are a covered dependent child and you turn age 26, regardless of marital status.

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

misconduct.

Enrolling in TCC. Get the RI 79-27, which describes TCC, from your employing or

retirement office or from www.opm.gov/healthcare-insurance. It explains what you have

to do to enroll.

Alternatively, you can buy coverage through the Health Insurance Marketplace where,

depending on your income, you could be eligible for a new kind of tax credit that lowers

your monthly premiums. Visit www.HealthCare.gov to compare plans and see what your

premium, deductible, and out-of-pocket costs would be before you make a decision to

enroll. Finally, if you qualify for coverage under another group health plan (such as your

spouse’s plan), you may be able to enroll in that plan, as long as you apply within 30 days

of losing FEHB Program coverage.

We also want to inform you that The Patient protection and Afordable Care Act (ACA) did

not eliminate TCC or change the TCC rules.

Temporary Continuation

of Coverage (TCC)

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

to convert. You must contact us in writing 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 contact us in writing within 31 days after you are no

longer eligible for coverage.

Converting to individual

coverage

10 2018 GHI Health Plan FEHB Facts

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

not have to answer questions about your health, a waiting period will not be imposed and

your coverage will not be limited due to pre-existing conditions. When you contact us, we

will assist you in obtaining information about health benefits coverage inside or outside

the Affordable Care Act’s Health Insurance Marketplace in your state. For assistance in

finding coverage, please contact us at 877 842-3625 or visit our website at www.

emblemhealth.com/federal

If you would like to purchase health insurance through the Affordable Care Act's Health

Insurance Marketplace,please visit www.HealthCare.gov. This is a website provided by

the U.S. Department of Health and Human Services that provides up-to-date information

on the Marketplace.

Health Insurance

Marketplace

11 2018 GHI Health Plan FEHB Facts

Section 1. How this plan works

This Plan offers two distinct benefit packages, High Option Preferred Provider Option (PPO) with Point of Service (POS)

coverage and Standard Option Exclusive Provider Option (EPO) coverage. GHI seeks efficient and effective delivery of

health services. By controlling unnecessary or inappropriate care, we can afford to offer a comprehensive range of benefits.

We strongly encourage you to select a personal GHI participating doctor who will provide your care within the Plan’s

participating provider network. This will ensure that you pay only the designated deductible, copayment, or coinsurance for

all covered services. GHI is solely responsible for the selection of the providers in our service area. Please contact us for a

copy of our most recent provider directory or visit us online at www.emblemhealth.com/federal for the most up-to-date

information on our provider network.

In addition to providing comprehensive health care services for illness and injury, we emphasize preventive benefits such as

routine office visits, physicals, immunizations, and well-baby care. We encourage you to seek medical attention at the first

sign of illness. Whenever you need services, you may choose to obtain them from your personal doctor within the Plan’s

provider network. If you are enrolled in the High Option with POS coverage, you may seek treatment outside our

participating provider network. However, you will pay a substantial portion of the charges for electing non-participating

providers and the available benefits may not be as comprehensive as benefits within the GHI network.

You should join a plan because you prefer the plan’s benefits, not because a particular provider may be available. We

cannot guarantee that any one physician, hospital, or other provider will be available and/or remain under contract

with us. You cannot change plans because a provider leaves our Plan.

General Features of our High Option with POS coverage

The enrollment codes for the High Option with POS are 801 (Self only) and 802 (Self and Family) and 803 (Self Plus One).

If you are enrolled in our High Option with POS coverage, you have access to in-network covered care from participating

providers under our Preferred Provider Option (PPO) or you may obtain covered care for certain services from non-network

providers under POS benefits. Please refer to Section 5(i) High Option Point of Service Benefits for specific information on

the POS coverage. Our High Option coverage offers a PPO network(s) of participating providers and uses provider selection

standards, utilization management, and quality assessment techniques to complement negotiated fee reductions as an

effective strategy for long term cost savings. Your out-of-pocket costs are lower when you seek covered care from within our

PPO network because participating providers have agreed to accept GHI’s schedule of allowances or negotiated rate as

payment in full for a covered service. You will only owe your deductible, copayment and/or coinsurance for covered

services.

The High Option coverage POS feature allows you freedom of choice in seeking care from non-network providers. However,

your out-of-pocket costs are much higher as covered care will be subject to a deductible, copayment, and coinsurance plus

any portion of the charge that exceeds our fee schedule allowance for a covered service. Non-network providers do not have

a contract with us and have not agreed to accept GHI’s allowance or negotiated rate as payment in full. Consequently, you

owe all balances after we determine our payment for services from non-network or non-participating providers.

General Features of our Standard Option coverage

The enrollment codes for the Standard Option coverage are 804 (Self only) and 805 (Self and Family) and 806 (Self Plus

One). If you are enrolled in our Standard Option coverage, you have access to covered care only from within our network

participating providers under our Exclusive Provider Option (EPO). We will not cover care that you receive from non-

network (non-participating) providers. Contracted providers within our EPO network have agreed to accept our schedule of

allowances or negotiated rate as payment in full for a covered service. Our EPO offers a network(s) of participating providers

and uses provider selection standards, utilization management, and quality assessment techniques to complement negotiated

fee reductions as an effective strategy for long term cost savings. Since you must seek care from within the EPO network,

you will only owe your deductible, copayment and/or coinsurance for covered services. You are not responsible for balances

that exceed our payment for covered services from EPO network providers.

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.

12 2018 GHI Health Plan Section 1

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.

When you use a participating hospital, keep in mind that the professionals who provide services to you in the hospital

may not all be participating providers. When you receive emergency and non-emergency services at a participating

hospital but are seen by a non-participating anesthesiologist, radiologist, pathologist, or assistant surgeon, we will calculate

payment based on an allowance that we determine under the High and the Standard options. Our allowance may not cover

the full charges and you will owe that portion of the charges that exceeds our payment. This policy does not apply

to services that you receive at non-participating hospitals.

When you use non-participating hospitals for covered care under the High option, we will apply POS benefits

to covered services from all non-participating providers which means that our allowance will be 50% of the fee schedule.

You are responsible for the out of network deductible and all charges that exceed our payment which could be a considerable

expense. Under the Standard Option benefit package, we do not cover care from non-participating providers and will

not pay them for covered services even if Medicare is your primary health insurance coverage. To get full maximum use of

the Standard Option package, you must use GHI's participating EPO provider network for all covered services.

Out-of-Network Services & Surprise Bills. If your claim was for services from a non-participating provider, the claim may

be for a “surprise bill,” giving you protection from out-of-pocket costs in excess of what you would have paid in-network for

the services. Please contact us at the number on the back of your member ID card or visit our website at emblemhealth.com/

outofnetwork for more information about what constitutes a “surprise bill” and what you should do if you think your claim

was for a “surprise bill.”

Please refer to the emergency benefits for information concerning emergency services.

Catastrophic protection

We protect you against catastrophic out-of-pocket expenses for covered services. The IRS limits out-of-pocket expenses for

covered services obtained from participating providers, including deductibles and copayments, to no more than $6,850 for

Self-Only enrollment, or $13,700 for a Self Plus One or Self and Family enrollment. Your specific plan limits may differ.

Your annual out-of-pocket expenses for covered services obtained from non-participating providers, including deductibles

and copayments, cannot exceed $15,000 per person.

Your rights and responsibilities

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/healthcare-insurance/healthcare ) lists the specific

types of information that we must make available to you. Some of the required information is listed below.

•GHI has been in continuous existence for over seventy (70) years.

•GHI is a Not for Profit New York company.

You are also entitled to a wide range of consumer protection and have specific responsibilities as a member of this Plan. You

can view the complete list of these rights and responsibilities by visiting the EmblemHealth website, www.emblemhealth.

com. You can also contact us to request that we mail a copy to you.

If you want more information about us, call (877) 842-3625, or write to GHI, PO Box 1701, New York, NY 10023-9476. You

may also visit our website at www.emblemhealth.com/federal.

By law, you have the right to access your personal health information (PHI). For more information regarding access to PHI,

visit the EmblemHealth website at www.emblemhealth.com/federal to obtain a Notice of our Privacy Practices. You can also

OPM requires that FEHB plans be accredited to ensure that plan operations and care management meet or exceed standards

that have been validated by an independent non-profit organization.

GHI holds the following accreditations: URAC

13 2018 GHI Health Plan Section 1

To learn more about accreditation, please visit the following websites: URAC (www.URAC.org)

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 with us in the High Option you must live or work in our service area. Our service area is: all of New York and the

New Jersey counties of Bergen, Essex, Hudson, Middlesex, Monmouth, Morris, Passaic, Somerset, Sussex and Union.

To enroll with us in the Standard Option, you must live or work in our service area. Our service area is: New York City (the

Boroughs of Manhattan, Brooklyn, Bronx, Queens, and Staten Island) all of Nassau, Suffolk, Rockland, Westchester Broome,

Cayuga, Chemung, Columbia, Cortland, Delaware, Dutchess, Franklin, Greene, Hamilton, Herimer, Jefferson, Lewis,

Madison, Oneida, Onondaga, Orange, Oswego, Otsego, Putnam, St. Lawrence, Schuyler, Steuben, Sullivan, Tioga,

Tompkins, Ulster , New Jersey counties of Bergen, Essex, Hudson, Middlesex, Monmouth, Morris, Passaic, Somerset,

Sussex and Union.

With the Standard Option, 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 moves outside of our service area, you can enroll in another plan. If your dependents live

out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service

plan or an HMO that has agreements with affiliates in other areas. If you or a family member moves, you do not have to wait

until Open Season to change plans. Contact your employing or retirement office.

14 2018 GHI Health Plan Section 1

Section 2. Changes for 2018

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.

Changes for High Option:

Your share of the non-Postal premium will increase for Self Only, Self Plus One and for Self and Family. See back of

brochure for 2018 payroll deductions.

Surprise Billing protection (See Page 13)

Changes for Standard Option:

Your share of the non-Postal premium will increase for Self Only, Self Plus One and for Self and Family. See back of

brochure for 2018 payroll deductions.

Surprise Billing protection (See Page 13)

15 2018 GHI Health Plan 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. Your member ID card will indicate the provider

network that is applicable to your coverage. You must show it whenever you receive

services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you

receive your ID card, use your copy of the Health Benefits Election Form, SF-2809,

your health benefits enrollment confirmation (for annuitants), or your electronic

enrollment system (such as Employee Express) confirmation letter.

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

enrollment, or if you need replacement cards, call us at (877) 842-3625. You may

also request replacement cards through the GHI website: www.emblemhealth.com

Identification cards

You get care from “Plan providers” and “Plan facilities.” Network providers file

claims for you and we reimburse them directly for covered services. You will only

pay copayments, deductibles, and/or coinsurance, and you will not have to file

claims. If you are enrolled in our High Option with POS Plan, you may also seek

care from non-Plan providers but you will have higher out-of-pocket costs than if

you had obtained care within the network and you are responsible for filing a claim

to GHI. Under the Standard Option coverage, we will not provide benefits for

services that you receive from non-network providers.

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.

Your ID card will indicate the GHI network for your coverage. We list Plan

providers in the provider directory, which we update periodically. The list is also on

our website. We recommend that you confirm that the provider is a participating

network provider prior to seeking services or upon scheduling an appointment.

• Plan providers

Plan facilities are hospitals and other facilities in our service area that we contract

with to provide covered services to our members. Your ID card will indicate the

GHI network for your coverage. We list Plan facilities in the provider directory,

which we update periodically. The list is also on our website. We recommend that

you confirm that the plan facility is a participating network provider prior to

seeking services or upon scheduling an appointment.

• Plan facilities

We provide benefits for the services of covered professional providers, as required

by Section 2706(a) of the Public Health Service Act (PHSA). Coverage of

practitioners is not determined by your state’s designation as a medically

underserved area (MUA).

Covered professional providers are medical practitioners who perform covered

services when acting within the scope of their license or certification under

applicable state law and who furnish, bill, or are paid for their health care services

in the normal course of business. Covered services must be provided in the state in

which the practitioner is licensed or certified.

• Covered Providers

Whether you are enrolled in the High Option with POS or the Standard Option

coverage, you are free to choose any participating provider within your Plan’s GHI

network. We strongly encourage you to select a doctor within the GHI network who

will provide your care.

What you must do to get

covered care

16 2018 GHI Health Plan Section 3

You may seek care from a doctor, dentist, podiatrist, qualified clinical psychologist,

optometrists, chiropractor, nurse, certified midwife, nurse practitioner/clinical

specialist, or qualified clinical social worker and any other duly-licensed, registered

or certified practitioner or privately-operated facility permitted to perform or render

care or service described in this brochure.

• Primary care

You may see the specialist whenever you and your family feel you need care.

Here are other things you should know about specialty care:

• If you have a chronic or 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 plan; or

- reduce our service area and you enroll in another FEHB plan

You may be able to continue seeing your specialist for up to 90 days after you

receive notice of the change. Contact us or, if we drop out of the Program, contact

your new plan.

If you are in the second or third trimester of pregnancy and you lose access to your

specialist based on the above circumstances, you can continue to see your specialist

until the end of your postpartum care, even if it is beyond the 90 days

• Specialty care

Your Plan primary care physician or specialist will make necessary hospital

arrangements and supervise your care. This includes admission to a skilled nursing

or other type of facility.

• Hospital care

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 (877) 842-3625. 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; or

• 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

You must get prior approval for certain services. Failure to do so will result in a

$125 per day up $250 penalty for hospital admissions. Members that do not receive

prior approval for certain medical services will be responsible for all charges.

The pre-service claim approval processes for inpatient hospital admissions (called

precertifcation) and for other services are detailed in this section. A pre-service

claim is any claim, in whole or in part, that requires approval from us in advance of

obtaining medical care or services. In other words, a pre-service claim for benefits

(1) requires precertification, prior approval or referral and (2) will result in a

reduction of benefits if you do not obtain precertification, prior approval, or referral.

You need prior Plan approval

for certain services

17 2018 GHI Health Plan Section 3

Pre-certification 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. We perform pre-admission review

for all non- emergency hospitalizations and must be notified of emergency hospital

admissions within a specified time frame. GHI’s Coordinated Care Department will

review the proposed hospital confinement to determine the length of stay in addition

to confirming the medical necessity of hospitalization.

Your physician must obtain precertification for the following services:

• Skilled Nursing Facility

• All elective or non-emergency hospital admissions

You do not need precertification in the following situations:

• You have another group health insurance policy that is the primary payer for the

hospital stay.

• Your Medicare Part A is the primary payor for the hospital stay. Note: If you

exhaust your Medicare hospital benefits and do not want to use your

Medicare lifetime reserve days, then we will become the primary payer and

you do need precertification.

Warning: If no one contacts us for precertification and we determine that the

hospital admission is not medically necessary, we will only pay for covered

medical services and supplies that are otherwise payable on an outpatient

basis.

• Inpatient hospital

admission

For certain services, you or your physician must obtain prior approval from us.

Before giving approval, we consider if the service is covered, is medically

necessary, and follows generally accepted medical practice. If your physician does

not contact us, we will not pay for the services. You or your physician must also

obtain prior approval for the following services:

• Organ/tissue transplants

• High-tech radiology

• High-tech nursing

• Infusion therapy

• Mental Health and Substance Abuse

• Infertility Services

• Bariatric Surgery

• Growth Hormone Therapy

• Gender Reassignment Surgery (GRS)

• Other services

When you use a network provider for covered services, the network provider will

initiate the precertification or prior approval process on your behalf. You, a family

member, or your physician must contact GHI’s Coordinated Care Program at (800)

223-9870 for precertification of the hospital admission:

• At least ten (10) days prior to the date of admission of elective procedures, or as

soon as reasonably possible;

• Within two (2) business days of an emergency admission, or as soon as

reasonably possible.

How to request precertification

for an admission or get prior

approval for Other services

18 2018 GHI Health Plan Section 3

Under the High Option with POS, you are responsible for ensuring that your

hospital admission has been precertified or your admission will be subject to a

penalty in addition to costs that you normally pay. To precertify your hospital

admission call GHI’s Coordinated Care Department at (800) 223-9870.

For non-urgent care claims, we will 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 judgement 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 let you know what information we need to complete

our review of the claim. You will then have up to 48 hours to provide the required

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.

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 (877) 842-3625. You may also call OPM's Health

Insurance II at (202) 606-3818 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 (877) 842-3625. If it is determined that your

claim is an urgent care claim, we will expedite our review (if we have not yet

responded to your claim.)

• Urgent care claims

A concurrent care claim involves care provided over a period of time or over a

number of treatments. We will treat any reduction or termination of our pre-

approved course of treatment before the end of the approved period of time or

number of treatments as an appealable decision. This does not include reduction or

termination due to benefit changes or if your enrollment ends. If we believe a

reduction or termination is warranted, we will allow you sufficient time to appeal

and obtain a decision from us before the reduction or termination takes effect.

• Concurrent care claims

19 2018 GHI Health Plan Section 3

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

to the expiration of the approved time period and this is also an urgent care claim,

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

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

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

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

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

discharged from the hospital.

• Emergency inpatient

admission

You do not need pre-certification of a maternity admission for a routine delivery.

However, if your medical condition requires you to stay more than 48 hours after a

vaginal delivery or 96 hours after a cesarean section, then your physician or the

hospital must contact us for pre-certification of additional days. Further, if your

baby stays after you are discharged, then your physician or the hospital must contact

us for pre-certification of additional days. Further, if your baby stays after you are

discharged, then your physician or the hospital must contact us for pre-certification

of additional days for your baby.

Note: When a newborn requires definitive treatment during or after the mother's

confinement, the newborn is considered a patient in his or her own right. If the

newborn is eligible for coverage, regular medical or surgical benefits apply rather

than maternity benefits.

• Maternity care

If your physician requests an extension of an ongoing course of treatment at lease

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

Failure to comply with pre - admission review or the concurrent review will result

in the following reductions in health benefit reimbursment: $125 per day to a

maximum of $250 per confinment as long as we determine that the inpatient

admission or service was medically necessary.

What happens when you do not

follow the precertification rules

when using non-network

facilities

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 follow the entire disputed claims process detailed in Section

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

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 the information was due. We

will base our decision on the information we already have. We will write to you

with our decision.

3. Write to you and maintain our denial.

• To reconsider a non-urgent

care claim

20 2018 GHI Health Plan Section 3

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

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

Step 1 of the disputed claims process detailed in Section 8 of this brochure.

Unless we request additional information, we will notify you of our decision within

72 hours after receipt of your reconsideration request. We will expedite the review

process, which allows oral or written requests for appeals and the exchange of

information by telephone, electronic mail, facsimile, or other expeditions methods.

• To reconsider an urgent

care claim

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

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

detailed in Section 8 of this brochure.

• To file an appeal with OPM

21 2018 GHI Health Plan Section 3

Section 4. Your costs for covered services

This is what you will pay out-of-pocket for covered care:

Cost-sharing is the general term used to refer to your out-of-pocket costs (e.g., deductible,

coinsurance, and copayments) for the covered care you receive.

Cost-sharing

A copayment is a fixed amount of money you pay to the network provider, facility,

pharmacy, etc. when you receive certain covered services.

Example: When you see your primary care physician you pay a copayment of $20 per

office visit under the High Option and $40 per office visit, and $10 per office visit for

dependent children to age 26, under the Standard Option.

Copayments

A deductible is a fixed expense you must pay for certain covered services and supplies

before we start paying benefits for them. Copayments do not count towards any

deductible.

The calendar year deductible for certain services is:

• For out of network services under the High Option the deductible is $500 for Self

Only, or $1000 for Self Plus One, or $1000 for Self and Family. Under a Self Only

enrollment, the deductible is considered satisfied and benefits are payable for you

when your covered out of network expenses applied to the calendar year deductible for

your enrollment reach $500 under High Option.

• For orthopedic and prosthetic devices, oxygen and other covered durable medical

equipment you pay $100 deductible per individual.

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: For orthopedic and prosthetic devises, after the applicable deductible is met you

pay 20% of the Plan’s fee schedule for a participating provider and 50% of the Plan’s fee

schedule and any difference between our allowance and the billed amount for a non-

participating provider

Coinsurance

When you use network providers, you are not responsible for differences between GHI’s

allowance and the provider’s charge. Non-network providers do not have an agreement

with GHI to accept the GHI allowance as payment in full. Under the High Option with

POS coverage, you are responsible for any amount of the charge that exceeds our payment

for services from non-network providers. The GHI fee schedule allowance for POS

services is 50% of the GHI fee schedule allowance for services provided by non-

participating providers. See

“Section 5(i) High Option Point of Services (POS) Benefits”

for more information.

Differences between our

Plan allowance and the

bill

22 2018 GHI Health Plan Section 4

After your (copayments deductibles and coinsurance) total $6,850 for Self Only or

$13,700 for Self Plus One, or $13,700 per Self and Family enrollment in any calendar

year, you do not have to pay any more for covered services. However, copayments,

deductibles and coinsurance for the following services do not count toward your

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

copayments for these services:

• Routine foot care

• Alternative treatments

• Educational classes, not mandated by State or Federal law

• Adult dental care services

• Vision care services

• Non-FEHB benefits

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

If you changed to this Plan during open season from a plan with a catastrophic protection

benefit and the effective date of the change was after January 1, any expenses that would

have applied to that plan’s catastrophic protection benefit during the prior year will be

covered by your old plan if they are for care you received in January before your effective

date of coverage in this Plan. If you have already met your old plan’s catastrophic

protection benefit level in full, it will continue to apply until the effective date of your

coverage in this Plan. If you have not met this expense level in full, your old plan will first

apply your covered out-of-pocket expenses until the prior year’s catastrophic level is

reached and then apply the catastrophic protection benefit to covered out-of-pocket

expenses incurred from that point until the effective date of your coverage in this Plan.

Your old plan will pay these covered expenses according to this year’s benefits; benefit

changes are effective January 1.

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

covered expenses already accumulated toward the catastrophic out-of-pocket limit of your

old option to the catastrophic protection limit of your new option.

Carryover

Facilities of the Department of 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

23 2018 GHI Health Plan Section 4

Section 5. Benefits

See page 15 for how our benefits changed this year and pages 86 and 87 for 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(a). Medical services and supplies provided by physicians and other health care professionals .................................27

Diagnostic and treatment services .....................................................................................................................................27

Telehealth Services ...........................................................................................................................................................28

Lab, X-ray and other diagnostic tests ................................................................................................................................28

Preventive care, adult ........................................................................................................................................................28

Preventive care, children ...................................................................................................................................................30

Maternity care ...................................................................................................................................................................31

Family planning ................................................................................................................................................................32

Infertility services .............................................................................................................................................................33

Allergy care .......................................................................................................................................................................33

Treatment therapies ...........................................................................................................................................................33

Physical and occupational therapies .................................................................................................................................34

Speech therapy ..................................................................................................................................................................35

Hearing services (testing, treatment, and supplies) ...........................................................................................................35

Vision services (testing, treatment, and supplies) .............................................................................................................35

Foot care ............................................................................................................................................................................36

Orthopedic and prosthetic devices ....................................................................................................................................37

Durable medical equipment (DME) ..................................................................................................................................37

Home health services ........................................................................................................................................................38

Chiropractic .......................................................................................................................................................................39

Alternative treatments .......................................................................................................................................................39

Educational classes and programs .....................................................................................................................................40

Section 5(b). Surgical and anesthesia services provided by physicians and other health care professionals .............................41

Surgical procedures ...........................................................................................................................................................41

Reconstructive surgery ......................................................................................................................................................42

Oral and maxillofacial surgery ..........................................................................................................................................43

Organ/tissue transplants ....................................................................................................................................................43

Anesthesia .........................................................................................................................................................................48

Section 5(c). Services provided by a hospital or other facility, and ambulance services ...........................................................49

Inpatient hospital ...............................................................................................................................................................49

Outpatient hospital or ambulatory surgical center ............................................................................................................50

Skilled nursing facility benefits ........................................................................................................................................51

Hospice care ......................................................................................................................................................................51

End of life care ..................................................................................................................................................................51

Ambulance ........................................................................................................................................................................51

Section 5(d). Emergency services/accidents ...............................................................................................................................52

Emergency within our service area ...................................................................................................................................53

Emergency outside our service area ..................................................................................................................................53

Ambulance ........................................................................................................................................................................53

Section 5(e). Mental health and substance misuse disorder benefits ..........................................................................................54

Mental health and substance misuse disorder benefits .....................................................................................................54

Autism Spectrum Disorders ..............................................................................................................................................55

Section 5(f). Prescription drug benefits ......................................................................................................................................56

Covered medications and supplies ....................................................................................................................................58

Section 5(g). Dental benefits .......................................................................................................................................................60

24 2018 GHI Health Plan High and Standard Option Section 5

Accidental injury benefit ...................................................................................................................................................60

Routine Dental Services ....................................................................................................................................................60

Section 5(h). Wellness and Other Special Features .....................................................................................................................62

Flexible benefits option .....................................................................................................................................................62

Large Case Management ...................................................................................................................................................62

Customer Service AnswerLine ..........................................................................................................................................62

Services for deaf and hearing impaired .............................................................................................................................62

High risk pregnancies ........................................................................................................................................................62

Centers of Excellence ........................................................................................................................................................62

Travel benefit/ services overseas ......................................................................................................................................62

Section 5(i). High Option Point of Service benefits ...................................................................................................................63

Summary of benefits for the High Option of the GHI Health Plan - 2018 .................................................................................86

Summary of benefits for the Standard Option of the GHI Health Plan - 2018 ...........................................................................87

25 2018 GHI Health Plan High and Standard Option Section 5

Section 5. High and Standard Option Benefits Overview

High and Standard Option

We offer two different benefits packages. We offer High Option with POS and Standard Option. We describe the available benefits

under each package in Section 5 of this brochure. Make sure that you review the benefits that are available under the option in which

you are enrolled. The enrollment codes for the High Option with POS are 801 Self Only and 803 Self Plus One and 802 for Self and

Family. The enrollment codes for Standard Option are 804 Self Only and 806 Self Plus One and 805 Self and Family.

The High and Standard Option Section 5 is divided into subsections. Please read the 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 filling advice, or more information about High and Standard Option benefits, contact us at 212/501-4GHI

(4444) or on our website at www.emblemhealth.com.

High Option with POS features:

•Access to GHI’s network of participating Preferred Provider Option (PPO)

•$20 copayment per office visit to participating network doctors

•$0 copayment for United States Preventive Task Force (USPSTF) recommended preventive care services

•$200 per day up to a maximum of $600 per admission for covered inpatient hospital admissions

•$0 copayment for up to 30 days of GHI approved skilled nursing facility benefits

•POS benefits for certain services from non-network providers (See Section 5(i) for specific information)

Standard Option features:

•Access to GHI’s Exclusive Provider Option (EPO) network

•$40 copayment per office visit to participating network doctors

•$0 copayment for United States Preventive Task Force (USPSTF) recommended preventive care services

•$10 copayment for dependent children who are under the age of 26 as long as the services are performed by a participating network

provider.

•$250 per day up to a maximum of $750 per admission for covered inpatient hospital admissions

•$0 copayment for up to 30 days of GHI approved skilled nursing facility benefits

Both Options offer the following unique features:

•Flexible benefit options

•Large Case Management

•Disease Management

•Customer Service Answer Line

•Services for deaf and hearing impaired

•Coverage for high risk pregnancies

•Centers of excellence for transplants/heart surgery/etc.

•Travel benefit/services overseas

26 2018 GHI Health Plan High and Standard Option

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

care professionals

High and Standard Option

Important things you should keep in mind about these benefits:

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

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

•Plan physicians must provide or arrange your care.

•POS (out of network) benefits apply only if you are enrolled in the High Option coverage.

•A facility copay applies to services that appear in this section but are performed in an ambulatory surgical

center or the outpatient department of a hospital.

•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 High Option has a $500 Self Only, or $1000 Self Plus One, $1000 Self and Family out-of-network

calendar year deductible.

•Invitro fertilization benefits apply only if you are enrolled in the High Option coverage.

Benefit Description You pay

Diagnostic and treatment services High Option Standard Option

Professional services of physicians

• In physician’s office

$20 per visit for participating

providers

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

$40 per office visit for participating

providers

$10 per office visit for children

(under age 26) for participating

providers

All charges for non-participating

providers

Professional services of physicians

• In an urgent care center

• Office medical consultations

• Second surgical opinion

• Routine physical examination every year

• Advance care planning

$20 per visit for participating

providers

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

$40 per office visit for participating

providers

$10 per office visit for children

(under age 26) for participating

providers

All charges for non-participating

providers

• During a hospital stay

• In a skilled nursing facility

• Initial examination of a newborn child covered

under a family enrollment

Nothing for participating providers

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

Nothing for participating providers

All charges for non-participating

providers

• At home $20 per visit for participating

providers

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

$40 per office visit for participating

providers

$10 per office visit for children

(under age 26) for participating

providers

All charges for non-participating

providers

27 2018 GHI Health Plan High and Standard Option Section 5(a)

High and Standard Option

Benefit Description You pay

Telehealth Services High Option Standard Option

If your provider offers covered services using

Telehealth:

• Covered services will include the use of

electronic information and communication

technologies by a provider to deliver covered

services to you while your location is different

than your providers location.

$10 for consultations from physicians

providing Telehealth services

$5 for consultations from Dietitians/

Nutritionists providing Telehealth

services

$10 for consultations from physicians

providing Telehealth services

$5 for consultations from Dietitians/

Nutritionists providing Telehealth

services

Note: Covered services are subject to the same

utilization review and quality assurance

requirements and other terms and conditions of this

plan.

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

Tests, such as:

• Blood tests

• Urinalysis

• Non-routine Pap tests

• Pathology

• X-rays

• Non-routine mammograms

• CAT Scans/MRI

• Ultrasound

• Electrocardiogram and EEG

$20 per each diagnostic x-ray +

laboratory test performed by a

participating provider (a maximum of

two diagnostic copays will apply per

date of service)

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

$40 per each diagnostic x-ray +

laboratory test performed by a

participating provider (a maximum of

two diagnostic copays will apply per

date of service)

$10 copayment per each diagnostic x-

ray + laboratory test for children

(under age 26) when performed by a

participating provider (a maximum of

two diagnostic copays will apply per

date of service)

All charges for non-participating

providers.

Preventive care, adult High Option Standard Option

Routine screenings, such as:

• Total Blood Cholesterol

• Chlamydial infection

• Colorectal Cancer Screening, including

- Fecal occult blood test

- Sigmoidoscopy screening - every five (5)

years starting at age fifty (50)

- Colonoscopy screening - every ten (10) years

starting at age fifty (50)

Nothing for preventive services

performed by a participating provider

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

Nothing for preventive care

performed by a participating provider

All charges for non-participating

providers

Routine Prostate Specific Antigen (PSA) test – one

annually for men age 40 and older

Nothing for preventive services

performed by a participating provider

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

Nothing for preventive services

performed by a participating provider

All charges for non-participating

providers

Well woman care -based on current

recommendations such as:

Nothing for preventive services

performed by a participating provider

Nothing for preventive services

performed by a participating provider

Preventive care, adult - continued on next page

28 2018 GHI Health Plan High and Standard Option Section 5(a)

High and Standard Option

Benefit Description You pay

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

• Routine Pap test

• Human papillomavirus testing for women age

thirty (30) and up once every three years

• Cervical cancer screening (Pap smear)

• Chlamydia/Gonorhea screening

• Osteoporosis screening

• Breast cancer screening

• Counseling for sexually transmitted infections

• Counseling and screening for human immune-

deficiency virus

• Contraceptive methods and counseling

• Screening and counseling for interpersonal and

domestic violence

Nothing for preventive services

performed by a participating provider

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

Nothing for preventive services

performed by a participating provider

All charges for non-participating

providers

Routine mammogram – covered for women Nothing for preventive services

performed by a participating provider

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

Nothing for preventive services

performed by a participating provider

All charges for non-participating

providers.

Adult immunizations endorsed by the Centers for

Disease Control and Prevention (CDC): based on

the Advisory Committee on Immunization and

Practices (ACIP)

• Tetanus-diptheria (Td) booster – once every 10

years, ages 19 and over (except as provided for

under Childhood immunizations)

• Influenza vaccine annually

• Pneumococcal vaccine, age 65 and over

• Varicella (Chickenpox) – for all persons aged

19-49

• Tetanus, Diptheria and Pertussis (TDAP) – for

persons aged 19-64, with a booster every 10

years

• Shingles vaccine, age 50 and over

Nothing for preventive services

performed by a participating provider

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

Nothing for preventive services

performed by a participating provider

All charges for non-participating

providers

Note: Any procedure, injection, diagnostic service,

laboratory, or x-ray service done in conjunction

with a routine examination and is not included in

the preventive listing of services will be subject to

the applicable member copayments, coinsurance

and deductible.

Preventive care, adult - continued on next page

29 2018 GHI Health Plan High and Standard Option Section 5(a)

High and Standard Option

Benefit Description You pay

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

Note: A complete list of preventive care services

recommended under the U.S. Preventive Services

Task Force (USPSTF) is available online at www.

uspreventiveservicestaskforce.org/Page/Name/

uspstf-a-and-b-recommendations/

HHS: www.healthcare.gov/preventive-care-

benefits/

CDC:www.cdc.gov/vaccines/schedules/index.html

Women's preventive services:

https://www.healthcare.gov/preventive-care-

women/

For additional information:

www.healthfinder.gov/myhealthfinder/default.aspx

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.

Preventive care, children High Option Standard Option

• Well-child visits examinations, and

immunizations as described in the Bright

Futures Guidelines provided by the American

Academy of Pediatrics

Nothing for participating providers

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

Nothing for participating providers

All charges for non- participating

providers

Examinations, limited to:

• Examinations for amblyopia and strabismus -

limited to one screening examination (ages 3

through 5)

• Ear exams to determine the need for hearing

correction

• Examinations done on the day of immunizations

(ages 3 up to age 22)

Nothing for participating providers

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

Nothing for participating providers

All charges for non-participating

providers

Note: Any procedure, injection, diagnostic service,

laboratory, or x-ray service done in conjunction

with a routine examination and is not included in

the preventive listing of services will be subject to

the applicable member copayments, coinsurance

and deductible.

Preventive care, children - continued on next page

30 2018 GHI Health Plan High and Standard Option Section 5(a)

High and Standard Option

Benefit Description You pay

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

Note: A complete list of preventive care services

recommended under the U.S. Preventive Services

Task Force (USPSTF) is available online at www.

uspreventiveservicestaskforce.org/Page/Name/

uspstf-a-and-b-recommendations/

HHS: www.healthcare.gov/preventive-care-

benefits/

CDC:www.cdc.gov/vaccines/schedules/index.html

Women's preventive services:

https://www.healthcare.gov/preventive-care-

women/

For additional information:

www.healthfinder.gov/myhealthfinder/default.aspx

Note: For a complete list of the American

Academy of Pediatrics Bright Futures Guidelines

go to www.brightfutures.asp.org/Pages/default.

aspx

Maternity care High Option Standard Option

Complete maternity (obstetrical) care, such as:

• Screening for gestational diabetes for pregnant

women after 24 weeks.

• Prenatal care

• Delivery

• Postnatal care

Note: Here are some things to keep in mind:

• You do not have to precertify your vaginal

delivery; see page 19 for other circumstances,

such as extended stays for you or your baby.

• You may remain in the hospital up to 48 hours

after a vaginal delivery and 96 hours after a

cesarean delivery. We will extend your inpatient

stay if medically necessary.

• We cover routine nursery care of the newborn

child during the covered portion of the mother’s

maternity stay. We will cover other care of an

infant who requires non-routine treatment only

if we cover the infant under a Self Plus One or

Self and Family enrollment. Surgical Benefits,

not maternity benefits, apply to circumcision if

this is the case.

• We pay hospitalization and surgeon services

(delivery) the same as for illness and injury.

$20 copay for first visit only (for

prenatal and postnatal care from a

participating provider)

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

$40 copay for first visit only (for all

prenatal and postnatal care from a

participating provider.

All charges for non-participating

providers

Maternity care - continued on next page

31 2018 GHI Health Plan High and Standard Option Section 5(a)

High and Standard Option

Benefit Description You pay

Maternity care (cont.) High Option Standard Option

• Hospital services are covered under Section 5(c)

and Surgical benefits (Section 5b)

Note: When a newborn requires definitive

treatment during or after the mother's confinement,

the newborn is considered a patient in his or her

own right. If the newborn is eligible for coverage,

regular medical or surgical benefits apply rather

than maternity benefits.

$20 copay for first visit only (for

prenatal and postnatal care from a

participating provider)

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

$40 copay for first visit only (for all

prenatal and postnatal care from a

participating provider.

All charges for non-participating

providers

• Breastfeeding support, supplies and counseling

for each birth

• Screening for gestational diabetes for pregnant

women

Nothing Nothing

Family planning High Option Standard Option

Contraceptive counseling on an annual basis Nothing Nothing

A range of voluntary family planning services for

women, limited to:

• Voluntary sterilization (See Surgical procedures

Section 5b)

• Surgically implanted contraceptives (such as

Norplant)

• Injectable contraceptive drugs (such as Depo

provera)

• Intrauterine devices (IUDs)

• Diaphragms

Note: We cover oral contraceptives under the

prescription drug benefit.

Nothing for participating providers

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

Nothing for participating providers

All charges for non-participating

providers

Voluntary family planning services for men,

limited to:

• Voluntary sterilization (See Surgical procedures

Section 5b)

$20 per visit for participating

providers

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

$40 per visit for participating

providers

All charges for non-participating

providers

Not covered:

•

Reversal of voluntary surgical sterilization

•

Genetic testing and counseling

All charges All charges

32 2018 GHI Health Plan High and Standard Option Section 5(a)

High and Standard Option

Benefit Description You pay

Infertility services High Option Standard Option

Diagnosis and treatment of infertility, such as:

• Artificial insemination (AI)

- Intravaginal insemination (IVI)

- Intracervical insemination (ICI)

- Intrauterinal insemination (IUI)

• Invitro fertilization - limited to three transfers

per lifetime (covered under the High Option

plan ONLY)

• Fertility drugs

Note: We cover injectable fertility drugs under

medical benefits and oral fertility drugs under the

prescription drug benefit.

$20 per visit for participating

providers

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

$40 per visit for participating

providers

All charges for non-participating

providers

Note: Invitro fertilization (IVF) is

NOT covered under Standard Option

Not covered:

• Cost of donor egg

• Cost of donor sperm

All charges All charges

Allergy care High Option Standard Option

• Testing and treatment

• Allergy injections

• Treatment materials (such as allergy serum)

$20 per visit for participating

providers

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

$40 per office visit for participating

providers

$10 per office visit for children

(under age 26) for participating

providers

All charges for non-participating

providers

Not covered:

•

Provocative food testing

•

Sublingual allergy desensitization

All charges All charges

Treatment therapies High Option Standard Option

• Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with

autologous bone marrow transplants is limited to

those transplants listed under Organ/Tissue

Transplants on page 43.

• Respiratory and inhalation therapy

• Dialysis – hemodialysis and peritoneal dialysis

• Intravenous (IV)/Infusion Therapy – Home IV

and antibiotic therapy

Nothing in a participating provider

doctor’s office

POS: In a doctors office, 50% of the

Plan’s fee schedule, for non-

participating providers, and any

difference between our fee schedule

and the billed amount (deductible

applies)

Nothing in a participating provider

doctor’s office

Note: Subject to prior approval, we

will provide up to ten out of area

hemodialysis treatments performed

by a non participating provider. You

are responsible for all charges that

exceed our allowable charges

• High-tech nursing and infusion therapy

- IV infusion therapy

- Parenteral and enteral therapy

- Other home IV therapies

Nothing for a participating provider

POS: All charges for non-

participating providers

Nothing for a participating provider

All charges for non-participating

providers

Treatment therapies - continued on next page

33 2018 GHI Health Plan High and Standard Option Section 5(a)

High and Standard Option

Benefit Description You pay

Treatment therapies (cont.) High Option Standard Option

Note: Contact us at (800) 223-9870 prior to

receiving services to ensure coverage.

• Intermittent home nursing service

- Provided by a Registered Nurse or Licensed

Practitioner

- Authorized and supervised by a doctor

- Intermittent visits less than 2 hours per day

Nothing for a participating provider

POS: All charges for non-

participating providers

Nothing for a participating provider

All charges for non-participating

providers

• Growth hormone therapy (GHT).

Note: This benefit is provided under our

Prescription Drug Benefits. Please see Section 5(f)

Prescription Drug benefits for information on

growth hormone.

Note: We only cover GHT when we preauthorize

the treatment before you begin 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

to Plan approval for certain services on page .

Applicable prescription drug copay

Note: Please see Section 5(f)

Prescription Drug Benefits.

Applicable prescription drug copay

Note: Please see Section 5(f)

Prescription Drug Benefits.

Not covered:

•

Treatment for experimental or investigational

procedures

All charges All charges

Physical and occupational therapies High Option Standard Option

• Note: We only cover therapy when ordered by a

provider. Cardiac rehabilitation following a

heart transplant, bypass surgery or a myocardial

infarction is provided for up to 32 sessions.

$20 per visit for participating

providers

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

$40 per visit for participating

providers

$10 per visit for children (under age

26) for participating providers

All charges for non-participating

providers

Not covered:

•

Long-term rehabilitative and habilitation

therapy

•

Exercise programs

All charges All charges

34 2018 GHI Health Plan High and Standard Option Section 5(a)

High and Standard Option

Benefit Description You pay

Speech therapy High Option Standard Option

Rehabilitation

Up to 60 visits of speech therapy each calendar

year for services from the following:

• Licensed or certified speech therapists

Habilitation

Up to 60 visits of speech therapy each calendar

year for services for:

• Speech therapy services that help a person keep,

learn or improve skills and functioning for daily

living. including:

• the management of limitations and disabilities

• services or programs that help maintain or

prevent deterioration in cognitive function.

Note: We Cover Habilitation Services in the

outpatient department of a Facility or in a Health

Care Professional’s office.

$20 per visit for participating

providers

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

$40 per visit for participating

providers

$10 per visit for children (under age

26) for participating providers

All charges for non-participating

providers

Hearing services (testing, treatment, and

supplies)

High Option Standard Option

• Diagnostic and treatment services for disease or

medical conditions affecting hearing

• For treatment related to illness or injury,

including evaluation and diagnostic hearing tests

performed by an M.D., D.O., or audiologist

• External hearing aids (See "Orthopedic and

Prosthetic devices")

$20 per visit for participating

providers

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

$40 per visit for participating

providers

$10 per visit for children (under age

26) for participating providers

All charges for non-participating

providers

Not covered: Hearing services that are not listed as

covered

All charges All charges

Vision services (testing, treatment, and

supplies)

High Option Standard Option

• Medical and surgical benefits for diagnosis and

treatment of diseases of the eye

$20 per visit for participating

provider

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

$40 per visit for participating

provider

$10 per visit for children (under age

26) for participating providers

All charges for non-participating

providers

• Examination of the eyes to determine if glasses

are required: once each calendar year

• One set of single vision or bifocal lenses (toric

kryptok or flat top 22mm): once each calendar

year

• One pair of basic frames from available styles:

one every two years

Nothing for services provided by

participating opticians, optometrists

and vision centers

POS: All charges for non-

participating providers

Nothing for services provided by

participating opticians, optometrists

and vision centers

All charges for non-participating

providers

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

35 2018 GHI Health Plan High and Standard Option Section 5(a)

High and Standard Option

Benefit Description You pay

Vision services (testing, treatment, and

supplies) (cont.)

High Option Standard Option

• Contact lenses for certain unusual medical

conditions (such as post cataract surgery or

keratoconus treatment)

• Replacement of broken lenses with lenses of the

same prescription and material originally

supplied

This benefit is administered by EyeMed -www.

eyemed.com

Nothing for services provided by

participating opticians, optometrists

and vision centers

POS: All charges for non-

participating providers

Nothing for services provided by

participating opticians, optometrists

and vision centers

All charges for non-participating

providers

Not covered:

•

Frames at any time unless lenses are also

provided

•

Replacement or repair of frames

•

Certain bifocals and trifocals, tinted, plastic and

oversized lenses and sunglasses and frames

other than basic frames; contact lenses for

cosmetic purposes

•

Charges in excess of the maximum GHI

allowance

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, including the routine

treatment of corns, calluses, and bunions, and the

partial removal of toenails

Note: There is a limit of 4 visits per calendar year.

$20 per visit for participating

provider

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

$40 per visit for participating

provider

All charges for non-participating

providers

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)

•

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 )

•

Orthotics devices for the feet

All charges All charges

36 2018 GHI Health Plan High and Standard Option Section 5(a)

High and Standard Option

Benefit Description You pay

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

• External hearing aids (Once every two years)

• Implanted hearing-related devices, such as bone

anchored hearing aids (BAHA) and cochlear

implants

• Orthopedic devices, such as braces

• Ostomy supplies

• 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 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.

20% of the Plan’s fee schedule for a

participating provider

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

Note: $100 annual deductible applies

per individual.

20% of the Plan’s fee schedule for a

participating provider

All charges for non-participating

providers

Note: $100 annual deductible applies

per individual.

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

•

Corrective appliances for treatment of

tempormandibular joint (TMJ) pain dysfunction

syndrome

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

• blood glucose monitors

20% of the Plan’s fee scheduled for a

participating provider

POS: 50% of the Plan’s fee schedule

and any difference between our

allowance and the billed amount for a

non-participating provider

All charges for non-participating

providers

Note: $100 annual deductible applies

per individual.

20% of the Plan’s fee scheduled for a

participating provider

All charges for non-participating

providers

Note: $100 annual deductible applies

per individual.

Durable medical equipment (DME) - continued on next page

37 2018 GHI Health Plan High and Standard Option Section 5(a)

High and Standard Option

Benefit Description You pay

Durable medical equipment (DME)

(cont.)

High Option Standard Option

Note: Call us at 800-223-9870 as soon as your Plan

physician prescribes this equipment. We will

arrange with a healthcare provider to rent or sell

you durable medical equipment at discounted rates

and will tell you more about this service when you

call.

20% of the Plan’s fee scheduled for a

participating provider

POS: 50% of the Plan’s fee schedule

and any difference between our

allowance and the billed amount for a

non-participating provider

All charges for non-participating

providers

Note: $100 annual deductible applies

per individual.

20% of the Plan’s fee scheduled for a

participating provider

All charges for non-participating

providers

Note: $100 annual deductible applies

per individual.

Not covered:

•

Air purification devices

•

Alarm and Alert Services

All charges All charges

Home health services High Option Standard Option

Services include:

• Part-time or intermittent nursing care by a

registered professional nurse (R.N.) or a home

health aide under the supervision of a registered

professional nurse

• Physical therapy

• Respiration or inhalation therapy

• Prescription drugs

• Medical supplies which serve a specific

therapeutic or diagnostic purpose

• Other medically necessary services or supplies

that would have been provided by a hospital if

the subscriber were still hospitalized

In order for us to cover home health care

services, the following conditions must be met:

1) Home health care must be provided and billed

by a certified home health agency, which has an

agreement with GHI to provide home health care

services; 2) You must remain under the care of a

medical doctor; 3) The services are provided

according to a plan of treatment approved by the

attending medical doctor; and 4)Medical evidence

substantiates that you would have required further

inpatient care had the home health care not been

available.

Nothing for a participating provider

POS: All charges for a non-

participating provider

Nothing for a participating provider

All charges for a non-participating

provider

Not Covered:

•

Homemaking services, including housekeeping,

preparing meals, or acting as a companion or

sitter

All charges All charges

Home health services - continued on next page

38 2018 GHI Health Plan High and Standard Option Section 5(a)

High and Standard Option

Benefit Description You pay

Home health services (cont.) High Option Standard Option

•

Services and supplies related to normal

maternity care

•

Services and supplies provided following a

noncovered hospital admission or admission to a

facility that is not a participating facility

•

Services and supplies provided when the

subscriber would not have required continued

inpatient care

•

Services and supplies provided by a non-

participating facility for home health care

•

High-tech nursing and infusion therapy

•

Nursing care requested by or for the

convenience of the patient's family and/or

private duty nursing

All charges All charges

Chiropractic High Option Standard Option

• Manipulation of the spine and extremities

• Adjustment procedures such as ultrasound,

electrical muscle stimulation, vibratory therapy,

and cold pack application

$20 per visit for participating

providers

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

$40 per visit for participating

providers

$10 per visit for children (under age

26) for participating providers

All charges for non-participating

providers

Not covered:

•

chiropractic services not shown as covered

All charges

Alternative treatments High Option Standard Option

Acupuncture – unlimited visits; no utilization

management under the Standard Option only

Services obtained through American Specialty

Health at www.choosehealthy.com 1 (877)

327-2746

• anesthesia

• pain relief

Note: We do not cover acupuncture treatment

under the High Option coverage

All charges $40 per visit for participating

providers

$10 per visit for children (under age

26) for participating providers

All charges for non-participating

providers

Not covered:

•

naturopathic services

•

hypnotherapy

•

biofeedback

All charges All charges

39 2018 GHI Health Plan High and Standard Option Section 5(a)

High and Standard Option

Benefit Description You pay

Educational classes and programs High Option Standard Option

Coverage is limited to:

• Diabetes self-management

• Cholesterol Management

• Arthritis

• Asthma

• Hepatitis C

• Multiple Sclerosis

• Depression

• Osteoporosis

• Nutritional Counseling

Nothing

For diabetes self management call

Diabetes Health Solutions at (800)

881-4008

For arthritis and osteoporosis

information call Arthritis Foundation

NYC Chapter at (212) 984-8713

To enroll in our Asthma Cholesterol

Management, Hepatitis C Multiple

Sclerosis & Depression program call

GHI Disease Management Line (212)

615-0363

Nothing

For diabetes self management call

Diabetes Health Solutions at (800)

881-4008

For arthritis and osteoporosis

information call Arthritis Foundation

NYC Chapter at (212) 984-8713

To enroll in our Asthma program call

(212) 615-0363

Tobacco Cessation Program

The Program is provided in partnership with the

American Cancer Society’s Quit For Life

(ACSQFL) program implemented by Free & Clear,

a vendor with expertise in smoking

cessation. Participation is initiated by a phone call

to the call center. Under the program, you have

access to the following:

• Unlimited telephonic access to professional

counselors;

• Educational information tailored to the

member’s stage of readiness to quit;

• Access to ACSQFL Web site; and

• Full coverage for smoking cessation

pharmaceutical products (Nicotine Patch, Gum,

Lozenge, Bupropion (generic Zyban®) and

Chantix™).

Note - See Section 5(f) Prescription Drug Benefits

for information on physician prescribed smoking

cessation medication. See Section 5(e) for

information on group and individual

psychotherapy.

Nothing Nothing

40 2018 GHI Health Plan High and Standard Option Section 5(a)

Section 5(b). Surgical and anesthesia services provided by physicians and other

health care professionals

High and Standard Option

Important things you should keep in mind about these benefits:

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

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

•Plan physicians must provide or arrange your care.

•The High Option out of network calendar year deductible is: $500 for Self Only, or $1000 for Self Plus One

or $1000 for Self and Family.

•POS (out of network) benefits and deductibles apply only if you are enrolled in the High Option coverage. If

you are enrolled in the Standard Option EPO, you must use participating providers within the EPO network.

•Be sure to read Section 4,

Your costs for covered services

, for valuable information about how cost-sharing

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

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

surgical care. See Section 5(c) for charges associated with the facility (i.e. hospital, surgical center, etc.).

•YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES.

Please refer to the precertification information shown in Section 3 to be sure which services require

precertification and identify which surgeries require precertification.

Benefit Description You pay

Surgical procedures High Option Standard Option

A comprehensive range of services, such as:

• Operative procedures

• Treatment of fractures, including casting

• Normal pre- and post-operative care by the

surgeon

• 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)– see Services requiring our prior

approval on page 18.

• Insertion of internal prostethic devices. See 5

(a) – Orthopedic and prosthetic devices for

device coverage information.

• Voluntary sterilization (e.g., Tubal ligation,

Vasectomy)

• Treatment of burns

$20 per office based surgical

procedure for a participating provider

Nothing for a participating provider

in the hospital or a participating

ambulatory surgery center

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

See Section 5(c) for outpatient

hospital or ambulatory surgical center

copayments.

$40 per office based surgical

procedure for a participating provider

All charges for non-participating

providers

See Section 5(c) for outpatient

hospital or ambulatory surgical center

copayments

Not covered:

•

Reversal of voluntary sterilization

•

Stand-by services

All charges All charges

Surgical procedures - continued on next page

41 2018 GHI Health Plan High and Standard Option Section 5(b)

High and Standard Option

Benefit Description You pay

Surgical procedures (cont.) High Option Standard Option

•

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.

• Surgery to correct a condition that existed at or

from birth and is a significant deviation from the

common form or norm. Examples of congenital

anomalies are: protruding ear deformities; cleft

lip; cleft palate; birth marks; webbed fingers;

and webbed toes.

• Gender Reassignment Surgery (GRS) when all

Plan criteria are met. Pre-authorization is

required for all services.

$20 per office based procedure for

participating providers

Nothing for a participating provider

in the hospital or a participating

ambulatory surgery center

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

$40 per office based procedure for

participating providers

All charges for non-participating

providers

• All stages of breast reconstruction surgery

following a mastectomy, such as:

- surgery to produce a symmetrical appearance

on the other breast;

- treatment of any physical complications, such

as lymphedemas; or

- breast prostheses and surgical bras and

replacements (see Prosthetic devices).

Note: If you need a mastectomy, you may choose

to have the procedure performed on an inpatient

basis and remain in the hospital up to 48 hours

after the procedure.

$20 per office based procedure for

participating providers

Nothing for a participating provider

in the hospital or a participating

ambulatory surgery center

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

$40 per office based procedure for

participating providers

All charges for non-participating

providers

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

All charges All charges

42 2018 GHI Health Plan High and Standard Option Section 5(b)

High and Standard Option

Benefit Description You pay

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

• Removal of impacted teeth

• Other surgical procedures that do not involve the

teeth or their supporting structures.

$20 per office based procedure for

participating providers

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

$40 per office based procedure for

participating providers

All charges for non-participating

providers

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 other procedures involving the teeth or intra-

oral areas surrounding the teeth are not covered,

including any dental care involved in the

treatment of teporomandibular joint (TMJ) pain

dysfunction syndrome.

All charges All charges

Organ/tissue transplants High Option Standard Option

Solid organ transplants are limited to:

• Cornea

• Heart

• Heart/lung

• Lung: single/bilateral/lobar

• Liver

• Kidney

• Pancreas

• Kidney/Pancreas

• Intestinal transplants

- Isolated small intestine

- Small intestine with the liver

- Small intestine with multiple organs such as

the liver, stomach, and pancreas

• Autologous pancreas islet cell transplant (as an

adjunct to total or near total pancreatectomy)

only for patients with chronic pancreatitis

$20 per office based procedure for

participating providers

Nothing for a participating provider

in the hospital or a participating

ambulatory surgery center

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

$40 per office based procedure for

participating providers

$10 per office procedure for children

(under age 26) for participating

providers

Nothing for a participating provider

in the hospital or a participating

ambulatory surgery center

All charges for non-participating

providers

Organ/tissue transplants - continued on next page

43 2018 GHI Health Plan High and Standard Option Section 5(b)

High and Standard Option

Benefit Description You pay

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

Blood or marrow stem cell transplants. The Plan

extends coverage for the diagnoses as indicated

below.

• Allogeneic transplants for:

- Acute lymphocyic or non- lymphocyic (i.e.

myelogenous) leukemia

- Chronic Lymphocytic leukemia/small

lymphocytic lymphoma (CLL/SLL)

- Advanced Hodgkin’s lymphoma with

recurrence

- Advanced non-Hodgkin’s lymphoma with

recurrence

- Acute Myeloid Leukemia

- Marrow Failure and Related Disorders (i.e.

Fanconi's PNH, pure red cell aplasia)

- Chronic myelogenous leukemia

- Hemoglobinapathy

- Myelodysplasia/Mylodysplastic syndromes

- Severe combined immunodeficiency

- Severe or very severe aplastic anemia

- Amyloidosis

- Paroxysmal Nocturnal Hemoglobinuria

• Autologous transplants for:

- Acute lymphocytic or nonlymphocytic (i.e.,

myelogenous leukemia)

- Advanced Hodgkin's lymphoma

- Advanced non-Hodgkin's lymphoma

- Neuroblastoma

- Amyloidosis

• Autologous tandem transplants for:

- Recurrent germ cell tumors (including

testicular cancer)

- Multiple myeloma

- Denovo myeloma

$20 per office based procedure for

participating providers

Nothing for a participating provider

in the hospital or a participating

ambulatory surgery center

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

$40 peroffice based procedure for

participating providers

$10 per office procedure for children

(under age 26) for participating

providers

Nothing for a participating provider

in the hospital or a participating

ambulatory surgery center

All charges for non-participating

providers

Blood or marrow stem cell transplants for

Allogeneic transplants for

• Phagocytic/Hemophagocytic deficiency diseases

(e.g., Wiskott-Aldrich syndrome)

• Infantile malignant osteopetrosis

• Kostmann’s syndrome

• Leukocyte adhesion deficiencies

$20 per office based procedure for

participating providers

Nothing for a participating provider

in the hospital or a participating

ambulatory surgery center

$40 per office based procedure for

participating providers

$10 per office procedure for children

(under age 26) for participating

providers

Nothing for a participating provider

in the hospital or a participating

ambulatory surgery center

Organ/tissue transplants - continued on next page

44 2018 GHI Health Plan High and Standard Option Section 5(b)

High and Standard Option

Benefit Description You pay

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

• Mucolipidosis (e.g., Gaucher’s disease,

metachromatic leukodystrophy,

adrenoleukodystrophy)

• Mucopolysaccharidosis (e.g., Hunter’s

syndrome, Hurler’s syndrome, Sanfilippo’s

syndrome, Maroteaux-Lamy syndrome variants)

• Myeloproliferative disorders

• Myelodysplasia/Myelodysplastic Syndromes

• Sickle cell anemia

• X-linked lymphoproliferative syndrome

Autologous transplants for

• Multiple myeloma

• Testicular, mediastinal, retroperitoneal, and

ovarian germ cell tumors

• Breast cancer

• Epithelial ovarian cancer

• Ependymoblastoma

• Ewing’s sarcoma

• Medulloblastoma

• Pineoblastoma

• Waldenstrom’s macroglobulinemia

$20 per office based procedure for

participating providers

Nothing for a participating provider

in the hospital or a participating

ambulatory surgery center

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

$40 per office based procedure for

participating providers

$10 per office procedure for children

(under age 26) for participating

providers

Nothing for a participating provider

in the hospital or a participating

ambulatory surgery center

All charges for non-participating

providers

Mini-transplants (non-myeloblative, reduced

intensity conditioning) for covered transplants:

Subject to medical necessity

Tandem transplants for covered transplants:

Subject to medical necessity

$20 per office based procedure for

participating providers

Nothing for a participating provider

in the hospital or a participating

ambulatory surgery center

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

$40 peroffice based procedure for

participating providers

$10 per office procedure for children

(under age 26) for participating

providers

Nothing for a participating provider

in the hospital or a participating

ambulatory surgery center

All charges for non-participating

providers

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 for

Allogeneic transplants for

• Chronic lymphocytic leukemia/small

lymphocytic lymphoma (CLL/SLL)

• Hemoglobinopathies

$20 per office based procedure for

participating providers

Nothing for a participating provider

in the hospital or a participating

ambulatory surgery center

POS: 50% of the Plan’s fee schedule

and any difference between our fee

schedule and the billed amount for

non-participating providers

$40 peroffice based procedure for

participating providers

$10 per office procedure for children

(under age 26) for participating

providers

Nothing for a participating provider

in the hospital or a participating

ambulatory surgery center

All charges for non-participating

providers

Organ/tissue transplants - continued on next page

45 2018 GHI Health Plan High and Standard Option 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

• Myelodysplasia/Myelodysplastic syndromes

• Multiple myeloma

• Multiple sclerosis

Non-myeloablative allogeneic transplants or

Reduced intensity conditioning (RIC) for

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

myelogenous) leukemia

• Myelodysplasia/myelodysplastic syndromes

• Advanced Hodgkin’s lymphoma

• Advanced non-Hodgkin’s lymphoma

• Breast cancer

• Chronic lymphocytic leukemia

• Chronic myelogenous leukemia

• Colon cancer

• Early stage (indolent or non-advanced) small

cell lymphocytic lymphoma

• Chronic lymphocytic leukemia/small

lymphocytic lymphoma (CLL/SLL)

• Multiple myeloma

• Multiple sclerosis

• Myeloproliferative disorders

• Non-small cell lung cancer

• Ovarian cancer

• Prostate cancer

• Renal cell carcinoma

• Sarcomas

• Sickle cell disease

Autologous transplants for

• Chronic myelogenous leukemia

• Early stage (indolent or non-advanced) small

cell lymphocytic lymphoma

• Chronic lymphocytic leukemia/small

lymphocytic lymphoma (CLL/SLL)

• Small cell lung cancer

• Multiple sclerosis

• Systemic lupus erythematosus

$20 per office based procedure for

participating providers

Nothing for a participating provider

in the hospital or a participating

ambulatory surgery center

POS: 50% of the Plan’s fee schedule

and any difference between our fee

schedule and the billed amount for

non-participating providers

$40 peroffice based procedure for

participating providers

$10 per office procedure for children

(under age 26) for participating

providers

Nothing for a participating provider

in the hospital or a participating

ambulatory surgery center

All charges for non-participating

providers

Organ/tissue transplants - continued on next page

46 2018 GHI Health Plan High and Standard Option Section 5(b)

High and Standard Option

Benefit Description You pay

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

Blood or marrow stem cell transplants covered

only in a National Cancer Institute or National

Institutes of Health approved clinical trial at a

Plan-designated center of excellence and if

approved by the Plan’s medical director in

accordance with the Plan’s protocols for:

• Allogeneic transplants for

- Breast cancer

- Epithelial ovarian cancer

National Transplant Program (NTP)- We will cover

transplants approved as safe and effective for a

specific disease by the Federal Drug

Administration (FDA) or National Institute of

Health, or which our Medical Director determines

is medically necessary, appropriate and advisable

on a case-by-case basis. We will cover the medical

and hospital services, and related organ acquisition

costs. Eligibility for transplants will be determined

and approved in advance solely by our Medical

Director upon recommendation of your PCP.

Additionally, all transplants must be performed at

hospitals specifically approved and designated by

us to perform these procedures. Specialty

physician experts from our designated centers of

excellence will provide clinical review and support

to the Medical Director’s decision.

Limited Benefits – Treatment for breast cancer,

multiple myeloma, and epithelial ovarian cancer

may be provided in an NCI- or NIH-approved

clinical trial at a Plan-designated center of

excellence and if approved by the Plan’s medical

director in accordance with the Plan’s protocols.

$20 per office procedure for

participating providers

Nothing for a participating provider

in the hospital or a participating

ambulatory surgery center

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

$40 per office procedure for

participating providers

$10 per office procedure for children

(under age 26) for participating

providers

Nothing for a participating provider

in the hospital or a participating

ambulatory surgery center

All charges for non-participating

providers

Note:

• We cover related medical and hospital expenses

of the donor when we cover the recipient. We

cover donor screening tests for the actual solid

organ donor or up to four bone marrow/stem cell

transplant donors in additiona to the testing of

family members. Donor coverage is provided up

to a maximum of $10,000 per transplant.

• Travel expenses up to a maximum of $150 per

person per day and $10,000 per lifetime of the

recipient if the recipient patient lives more than

75 miles from the transplant center. This

includes food and lodging for the recipient

patient and one adult family member (two, if the

recipient is a minor) to the city where the

transplant takes place.

A maximum of $150 per person per

day and $10,000 per lifetime.

A maximum of $150 per person per

day and $10,000 per lifetime.

Organ/tissue transplants - continued on next page

47 2018 GHI Health Plan High and Standard Option Section 5(b)

High and Standard Option

Benefit Description You pay

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

Note: The benefit period begins five (5) days prior

to surgery and extends for a period of up to one

year from the date of surgery.

A maximum of $150 per person per

day and $10,000 per lifetime.

A maximum of $150 per person per

day and $10,000 per lifetime.

Not covered:

•

Donor screening tests and donor search

expenses, except those performed for the actual

donor

•

Implants of artificial organs

•

Transplants not listed as covered

All charges All charges

Anesthesia High Option Standard Option

Professional services provided in –

• Hospital (inpatient)

Nothing for a participating provider

in the hospital or a participating

ambulatory surgery center

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

Nothing for a participating provider

in the hospital or a participating

ambulatory surgery center

All charges for non-participating

providers

Professional services provided in –

• Hospital (outpatient)

• Skilled nursing facility

• Ambulatory surgical center

• Office

Nothing for a participating provider

in the hospital or a participating

ambulatory surgery center

POS: 50% of the Plan’s fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount

(deductible applies)

Nothing for a participating provider

in the hospital or a participating

ambulatory surgery center

All charges for non-participating

providers

Not covered:

•

Services administered by the same practitioner

performing surgery

All charges All charges

48 2018 GHI Health Plan High and Standard Option Section 5(b)

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

services

High and Standard Option

Important things you should keep in mind about these benefits:

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

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

•A participating provider must provide or arrange all inpatient Hospital care and you must be hospitalized in a

participating facility.

•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 OF HOSPITAL STAYS. Please refer to

Section 3 to be sure which services require precertification.

Benefit Description You pay

Inpatient hospital High Option Standard Option

Room and board, such as

• Ward, semiprivate, or intensive care accommodations;

• General nursing care; and

• Meals and special diets.

Note: If you want a private room when it is not medically

necessary, you pay the additional charge above the

semiprivate room rate.

$200 per day up to a maximum of

$600 per inpatient admission

Note: Except for medically

necessary emergency admissions

you pay all charges for an

inpatient admission at a non-

particating facility.

$250 per day up to a maximum of

$750 per inpatient admission

Note: Except for medically

necessary emergency admissions

you pay all charges for an

inpatient admission at a non-

particating facility.

Other hospital services and supplies, such as:

• Operating, recovery, maternity, and other treatment

rooms

• Prescribed drugs and medicines

• Diagnostic laboratory tests and X-rays

• Administration of blood and blood products

• 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.)

Nothing (included in the inpatient

hospital cost sharing)

Note: Except for medically

necessary emergency admissions

you pay all charges for an

inpatient admission at a non-

particating facility

Nothing (included in the inpatient

hospital copay)

Note: Except for medically

necessary emergency admissions

you pay all charges for an

inpatient admission at a non-

particating facility

Not covered:

•

Custodial care, rest cures, domiciliary or convalescent

care

•

Non-covered facilities, such as nursing homes and

schools

All charges All charges

Inpatient hospital - continued on next page

49 2018 GHI Health Plan High and Standard Option Section 5(c)

High and Standard Option

Benefit Description You pay

Inpatient hospital (cont.) High Option Standard Option

•

Personal comfort items, such as telephone, television,

barber services, guest meals and beds

•

Private nursing care

•

Long term rehabilitation

All charges All charges

Outpatient hospital or ambulatory surgical

center

High Option Standard Option

• Operating, recovery, and other treatment rooms

• Prescribed drugs and medicines

• 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. Conditions for which hospitalization would

be covered include hemophilia, impacted teeth, and heart

disease; the need for anesthesia, by itself, is not such a

condition. For approved inpatient admissions, you are

responsible for the applicable hospital admission copay

(see inpatient hospital benefits).

$150 copayment

POS: 50% of the Plan’s fee

schedule for non-participating

providers, and any difference

between our fee schedule and the

billed amount

$150 copayment

All charges for a non-participating

provider

• Diagnostic laboratory tests, X-rays, and pathology

services

$20 copayment

POS: 50% of the Plan's fee

schedule and any difference

between our fee schedule and the

billed amount for non-

participating providers (deductible

applies)

$40 copayment

All charges for non-participating

providers

• Chemotherapy and radiation Nothing for chemotherapy and

radiation provided in a

participating facility

POS: 50% of the Plan’s fee

schedule and any difference

between our fee schedule and the

billed amount for non-

participating providers (deductible

applies).

Nothing for chemotherapy and

radiation provided in a

participating facility

All charges for non-participating

providers

Not covered: Blood and blood derivatives replaced by the

member

All charges All charges

50 2018 GHI Health Plan High and Standard Option Section 5(c)

High and Standard Option

Benefit Description You pay

Skilled nursing facility benefits High Option Standard Option

Skilled nursing facility (SNF) care is limited to 30 days

per calendar year and includes the following:

• Bed, board and general nursing care

• Drugs, biologicals, supplied and equipment ordinarily

provided or arranged by the skilled nursing facility

when prescribed by your doctor as governed by

Medicare guidelines.

Nothing for a participating

provider

POS: All charges for a non-

participating provider

Nothing for a participating

provider

All charges for a non-participating

provider

Not Covered:

•

Custodial care

All charges All charges

Hospice care High Option Standard Option

Supportive and palliative care for a terminally ill member

in the home or hospice facility. Services include:

• inpatient/outpatient care; and

• family counseling under the direction of a doctor.

Note: Your provider must certify that you are in the

terminal stages of illness, with a life expectancy of

approximately six months or less. The hospice must have

an agreement with us or recognized by Medicare as a

hospice.

Nothing for a participating

provider

Nothing for a participating

provider

Not covered: Independent nursing, homemaker services All charges All charges

End of life care High Option Standard Option

Acute care provided in a licensed Article 28 facility or

acute care facility that specializes in terminally ill

patients, for members diagnosed with advanced cancer

with less than sixty (60) days to live.

Nothing Nothing

Not covered: Independent nursing, homemaker services All charges All charges

Ambulance High Option Standard Option

Ambulance services for each trip to or from a hospital for

medically necessary services. This includes the use of an

ambulance for emergency outpatient care and maternity

care, to the nearest facility.

All charges in excess of $100.

Note: We will not pay more than

$100 for covered ambulance

services.

All charges in excess of $100.

Note: We will not pay more than

$100 for covered ambulance

services.

Not covered:

•

Air ambulance

•

Ambullette services

All charges All charges

51 2018 GHI Health Plan High and Standard Option Section 5(c)

Section 5(d). Emergency services/accidents

High and Standard Option

Important things you should keep in mind about these benefits:

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

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

•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.

•GHI will determine reimbursement for emergency services from non-participating providers based on a

lesser of 100% of the 90th percentile of FAIR Health Prevailing Healthcare Charges System for Emergency

Professional charges and Emergency Admission Professional Charges or the provider's billed charge.

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 is emergency care? Emergency care means care for a medical or behavioral condition, the onset of which is sudden, that

manifests itself by symptoms of sufficient severity, including severe pain, that a prudent layperson, possessing an average knowledge

of medicine and health, could reasonably expect that absence of immediate medical attention to result in:

•placing the health of the person afflicted with such condition in serious jeopardy, or in the case of a behavioral condition placing the

health of such person or others in serious jeopardy;

•serious impairment to such person's bodily functions;

•serious dysfunction of any bodily organ or part of such person; or

•serious disfigurement of such person.

What to do in case of emergency. If you are in an emergency situation, please call your 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. It is your responsibility to ensure that the Plan has been promptly notified.

Emergencies within our service area. Benefits are available for care from non-Plan providers in a medical emergency only if delay

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

Emergencies outside our service area. Benefits are available for any medically necessary health service that is immediately

required because of injury or unforeseen illness.

Note: If you are admitted to the hospital from the Emergency Room, we waive the emergency care copay. A participating GHI

provider must provide your follow-up care. We cover care provided by a non-participating provider at 100% of the Plan’s fee

schedule.

52 2018 GHI Health Plan High and Standard Option Section 5(d)

High and Standard Option

Benefit Description You pay

Emergency within our service area High Option Standard Option

• Emergency medical/surgical care at a doctor's

office

• Emergency medical/surgical care at an urgent

care center

$20 per office visit for a participating

provider.

POS: Any difference between our

allowance and the billed amount for a

non-participating provider.

$40 per office visit for a participating

provider.

Any difference between our

allowance and the billed amount for a

non-participating provider.

• Emergency care as an outpatient

Note: Copay waived if admitted to the hospital. If

private physicians who are not hospital employees

provide the emergency care, you may receive a

separate bill for these services, which we will

process as a medical benefit.

$175 copay per hospital emergency

room visit.

POS: Any difference between our

allowance and the billed amount for a

non-participating provider

$175 copay per hospital emergency

room visit plus all charges that

exceed the emergency allowance for

non-participating hospitals.

Not covered: Elective care or non-emergency care All charges All charges

Emergency outside our service area High Option Standard Option

• Emergency medical/surgical care at a doctors’

office

• Emergency medical/surgical care at an urgent

care center

• Emergency care as an outpatient at a hospital,

including doctors’ services

$20 per office visit for a participating

provider.

POS: Any difference between our

allowance and the billed amount for a

non-participating provider

$40 per office visit for a participating

provider.

Any difference between our

allowance and the billed amount for a

non-participating provider.

Not covered: Elective care or non-emergency care All charges All charges

Ambulance High Option Standard Option

Professional ambulance service to or from a

hospital for medically necessary services. This

includes the use of an ambulance for emergency

outpatient care and maternity care, to the nearest

facility.

See 5(c) for non-emergency service.

All charges in excess of $100

Note: We do not pay more than $100

for covered ambulance services.

All charges in excess of $100

Note: We do not pay more than $100

for covered ambulance services.

Not covered: air ambulance and ambullette

services

All charges All charges

53 2018 GHI Health Plan High and Standard Option Section 5(d)

Section 5(e). Mental health and substance misuse disorder 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.

•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.

•Under the Standard Option, you must obtain care from within the participating provider network.

•Mental Health and Substance Misuse Disorder benefits are eligible for POS benefits under the High Option.

However, you are responsible for all balances that exceed our payment.

Benefit Description You pay

Mental health and substance misuse

disorder benefits

High Option Standard Option

All diagnostic and treatment services obtained

from a Plan provider and contained in a treatment

plan that we approve. The treatment plan may

include services, drugs, and supplies described

elsewhere in this brochure.

Note: Plan 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.

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.

• Professional services, including individual or

group therapy by providers such as psychiatrists,

psychologists, or clinical social workers

• Medication management

Nothing for outpatient mental health

care.

Nothing for outpatient mental health

care.

• Diagnostic tests Nothing Nothing

• Services provided by a hospital or other facility

• Services in approved alternative care settings

such as partial hospitalization, half-way house,

residential treatment, full-day hospitalization,

facility based intensive outpatient treatment

Nothing Nothing

• Facility charges of a non-participating general

hospital or facility

• Treatment by a non-participating professional

provider

Note: See Section 5(d) Emergency Benefits for

information on emergency services.

POS: 50% of the Plan's fee schedule

for non-participating providers, and

any difference between our fee

schedule and the billed amount.

All charges

Not Covered

• Services we have not approved

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.

54 2018 GHI Health Plan High and Standard Option Section 5(e)

High and Standard Option

Benefit Description You pay

Autism Spectrum Disorders High Option Standard Option

Inpatient and Outpatient Coverage for the

Treatment of Autism Spectrum Disorder

Coverage is provided for medically necessary and

appropriate services associated with the screening,

diagnosis and treatment of Autism Spectrum

Disorder. Services must be provided by an in-

network provider through Beacon Health Options.

There are no age, visit or annual benefit limits.

Treatment includes the following care and assistive

communication devices prescribed or ordered for

an individual diagnosed with Autism Spectrum

Disorder by a licensed physician or a licensed

psychologist:

• Behavioral Health Treatment;

• Psychiatric Care;

• Psychological Care;

• Medical care provided by a licensed health

provider;

• Therapeutic care, including therapeutic care

which is deemed habilitative or nonrestorative;

• Assistive Communication Devices;

• Applied Behavioral Analysis

Nothing Nothing

Not covered:

•

Services we have not approved.

•

Services received from out-of-network providers

55 2018 GHI Health Plan High and Standard Option Section 5(e)

Section 5(f). Prescription drug benefits

High and Standard Option

Important things you should keep in mind about these benefits:

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

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

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

•Federal law prevents the pharmacy from accepting unused medications.

•We will send each new enrollee a description of the prescription drug program and a mail order form/patient

profile and a preaddressed reply envelope. You may use your Plan identification card to access the

prescription drug benefits.

•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.

•Members must make sure their physicians obtain prior approval/authorizations for certain prescription drugs

and supplies before coverage applies. Prior approval/authorizations must be renewed periodically.

There are important features you should be aware of. These include:

•Who can write your prescription.A licensed physician or dentist, and in states allowing it, licensed or certified Physician

Assistant,Nurse Practitionerand Psychologist must prescribe your medication.

•Where you can obtain them. You may fill the prescription at a participating pharmacy by presenting your Plan Identification Card.

You must obtain certain generic maintenance drugs or name brand formulary drugs by mail order.

•We use a formulary. Our formulary is a list of effective medications and other items that we have approved for our members' use.

A special committee of medical and pharmacy professionals reviews the formulary annually. We add or delete items on the list

based on their findings. We have found that the drugs on our formulary are safe, effective, and therapeutic in the treatment of

disease or illness. Please call GHI Pharmacy Services 877-444-3614

for a copy of our formulary.

•These are the dispensing limitations. A participating pharmacy will provide up to a 30-day supply of your prescription. Under the

High Option Plan you will pay $20 for generic formulary drugs, $45 for name brand formulary drugs, $85 for non-formulary drugs

or 25% coinsurance up to maximum of $200 per prescription for speciality drugs. Under the Standard Option Plan you pay $15 for

generic formulary drugs $50 for name brand formulary drugs, $100 non-formulary drugs or 25% coinsurance up to a maximum of

$200 per script for speciality drugs

•Maintenance Medication by mail-order. Your prescription coverage includes a mail order program for all maintenance

medications. You must obtain a new prescription from your provider for a 90 day supply, to be sent to GHI Pharmacy Services.

Please call GHI Pharmacy Services at 877-444-3614. Specialty drugs and Sexual dysfunction drugs are not available by mail-order

and require prior approval.

•Step Therapy Prior Authorization Program. For prior authorization, your physician or you should call GHI Pharmacy Services

at 877-444-3614. Step Therapy programs apply edits to drugs in specific therapeutic classes at the point of service. Coverage for

second-line therapies is determined at the member level based on the presence or absence of first-line drugs in the member’s claims

history. Step Therapy coverage criteria are automated whenever possible so that rejects are further reduced. Only claims for

members whose histories do not show use of first-line drugs are rejected for payment at the point of service and online messaging is

sent to the pharmacy indicating that prior authorization is required for coverage of the second-line therapy.

•Drug Quantity Management Program. The Drug Quantity Management program manages prescription costs by ensuring that the

quantity of units supplied for each copayment is consistent with clinical dosing guidelines. The program is designed to support safe,

effective, and economic use of drugs while giving patients access to quality care. Clinicians maintain a list of quantity limit drugs,

which is based upon FDA-approved dosing guidelines and medical literature. Online edits help make sure optimal quantities of

medication are dispensed per copayment and per days’ supply.

•Diabetic Supplies Close Category Program. The Diabetic Supplies Category Program refers only to prescriptions for test strips

and meters. You will be granted authorization for test strips and meters when you present a prescription for a covered diabetic

supply product (Roche and J&J products are covered).

56 2018 GHI Health Plan High and Standard Option Section 5(f)

High and Standard Option

•A generic equivalent will be dispensed if it is available,unless your physician specifically requires a name brand. If you

receive a name brand drug when a Federally-approved generic drug is available, and your physician has not specified Dispense as

Written for the name brand drug, you have to pay the difference in cost between the name brand drug and the generic.

•You will be able to choose from pharmacies in the Express Advantage Network (EAN), provided by Express Scripts. This is a

smaller network that is available in addition to the larger ESI network of pharmacies you can choose from that are included in your

GHI FEHB plan. By choosing an EAN pharmacy, you could see smaller copays.

Why use a generic drug?

•Generic drugs may have unfamiliar names, but they are safe and effective.

•Generic drugs contain the same active ingredients, in the same dosage form as their brand name counterparts, and are manufactured

according to the same strict federal regulations.

•Generic drugs may differ in color, size, or shape, but they have the same strength, purity, and quality as the brand-name alternatives.

•Prescriptions filled with generic drugs often have lower co-payments. Therefore, you may be able to get the same health benefits at

a lower cost. You should ask your physician or pharmacist whether a generic version of your medications is available. By using a

generic drug, you may be able to receive the same high-quality medication but reduce your expenses.

When you have to file a claim. Please call GHI Pharmacy Services 1-877-444-3614 and we will send you a claim form. Under

normal circumstances, you do not have to file prescription drug claims. You simply present your GHI card to the participating

pharmacy and pay the appropriate copay.

57 2018 GHI Health Plan High and Standard Option Section 5(f)

High and Standard Option

Benefit Description You pay

Covered medications and supplies High Option Standard Option

We cover the following medications and supplies

prescribed by a Plan physician and obtained from

either a Plan pharmacy or through our mail order

program:

• Drugs for which a prescription is required by

Federal law of the United States

• FDA approved prescription drugs and devices

for birth control

• Fertility drugs (oral and injectable)

• Insulin

• Drugs to treat sexual dysfunction (with Prior

authorization)

• Disposable needles and syringes needed for the

administration of covered medication

• Smoking cessation drugs and medication,

including nicotine patches (up to 90-day supply)

• Intravenous fluids and medications for home use

through our Participating Provider network for

home infusion therapy

• Nutritional supplements for the treatment of

phenylketonuria, branched chain ketonuria,

galactosemia, and homocystinuria

Network Retail:

$20 generic

$45 brand name listed on the

preferred prescription drug formulary

$85 brand name drug not listed on the

preferred prescription drug formulary

25% coinsurance up to a maximum

of $200 per prescription for specialty

drugs

Network Mail Order: 90 day

supply

$40 generic

$90 brand name listed on the

preferred prescription drug formulary

$125 brand name drug not listed on

the preferred prescription drug

formulary.

Express Advantage Network (EAN)

$15 generic

$40 brand name listed on the

preferred prescription drug formulary

$80 brand name drug not listed on the

preferred prescription drug formulary

Network Retail:

$15 generic

$50 brand name listed on the

preferred prescription drug formulary

$100 brand name drug not listed on

the preferred prescription drug

formulary.

25% coinsurance up to a maximum

of $200 per prescription for specialty

drugs

Network Mail Order: 90 day

supply

$40 generic

$125 brand name listed on the

preferred prescription drug formulary

$170 brand name drug not listed on

the preferred prescription drug

formulary

Express Advantage Network (EAN)

$10 generic

$45 brand name listed on the

preferred prescription drug formulary

$95 brand name drug not listed on the

preferred prescription drug formulary

• Physician prescribed over-the-counter and

prescription smoking cessation medication

approved by the FDA to treat tobacco

dependence

• Insulin

• Diabetic supplies limited to:

- Disposable needles and syringes for the

administration of covered medications

• Vitamin D supplements for adults 65 years of

age and older

• Women's contraceptive medications and devices,

including the "morning after pill" as an over-the-

counter (OTC) emergency contraceptive drug.

Nothing Nothing

Preventive Care medications to promote better

health as recommended by ACA.

Nothing Nothing

Covered medications and supplies - continued on next page

58 2018 GHI Health Plan High and Standard Option Section 5(f)

High and Standard Option

Benefit Description You pay

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

The following drugs and supplements are covered

without cost-share, even if over-the-counter, are

prescribed by a health care professional and filled

at a network pharmacy.

• Aspirin (81 mg) for men age 45-79 and women

age 55-79 and women of childbearing age

• Folic acid supplements for women of

childbearing age (400 & 800 mcg)

• Vitamin D supplements (prescription strength)

(400 & 1000 units) for members 65 or older

• Fluoride tablets, solution (not toothpaste, rinses)

for children age 0-6

Note: To receive this benefit a prescription from a

doctor must be presented to pharmacy.

Nothing Nothing

Not covered:

•

Nonprescription medications

•

Drugs obtained at a non-participating pharmacy,

except for emergencies.

•

Vitamins, nutrients and food supplements not

listed a a covered benefit, even if a physician

prescribes or administers them

•

Medical supplies

•

Drugs and supplies for cosmetic purposes

•

Drugs to enhance athletic performance

•

Network Mail Order for Specialty Drugs

All charges All charges

59 2018 GHI Health Plan High and Standard Option Section 5(f)

Section 5(g). Dental benefits

High and Standard Option

Important things you should keep in mind about these benefits:

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

and are payable only when we determine they are medically necessary

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

FEHB Plan will be First/Primary payor of any Benefit payments and your FEDVIP Plan is secondary to your

FEHB Plan. See Section 9 Coordinating benefits with other coverage.

•Plan dentists must provide or arrange your care.

•We will cover dental care for accidental injury only as indicated within the benefits description.

•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.

•This Plan provides routine preventive dental coverage only. The emphasis is on prevention, with

preventive and minor diagnostic dental services covered with no copayments through Participating Plan

Dentists. Services by non-participating dentists are covered in accordance with the fees listed below. This

Plan does not provide benefits for minor restorative or major restorative dental services,

prosthodontics, endodontics, orthodontics, etc.

•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 caused by

external means and services must be completed

within one year.

Any difference between our fee

schedule and the actual charges.

Any difference between our fee

schedule and the actual charges.

Not covered:

•

Therapeutic service

•

Other dental services not shown as covered

•

Charges which exceed the Plan’s fee schedule

All charges All charges

Routine Dental Services High Option Standard Option

Examinations (maximum 2 per calendar year) Nothing for a participating provider

POS: All charges in excess of $10.00

Nothing for a participating provider

All charges for non-participating

providers.

Prophylaxes (under age 12 - maximum 2 per

calendar year)

Nothing for a participating provider

POS: All charges in excess of $7.00

Nothing for a participating provider

All charges for non-participating

providers

Prophylaxes (over age 12 - maximum 2 per

calendar year)

Nothing for a participating provider

POS: All charges in excess of $10.00

Nothing for a participating provider

All charges for non-participating

providers

Emergency visits for relief of pain (1 per calendar

year)

Nothing for a participating provider

POS: All charges in excess of $10.00

Nothing for a participating provider

Routine Dental Services - continued on next page

60 2018 GHI Health Plan High and Standard Option Section 5(g)

High and Standard Option

Benefit Desription You Pay

Routine Dental Services (cont.) High Option Standard Option

All charges for non-participating

provider

X-rays (Full-mouth series, 1 every 3 years) Nothing for a participating provider

POS: All charges in excess of $20.00

Nothing for a participating provider

All charges for non-participating

providers

Bitewings (4 per calendar year) Nothing for a participating provider

POS: All charges in excess of $2.50

per each bitewing

Nothing for a participating provider

All charges for non-participating

providers

Space maintainers Nothing for a participating provider

POS: All charges in excess of $65.00

Nothing for a participating provider

All charges for non-participating

providers

Fluoride Treatments – dependent children to age

Nothing for a participating provider

POS: All charges in excess of $5.00

Nothing for a participating provider

All charges for non-par provider

61 2018 GHI Health Plan High and Standard Option Section 5(g)

Section 5(h). Wellness and Other 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

• Alternative benefits are subject to our ongoing review.

• 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 we may withdraw it at

any time and resume regular contract benefits.

• 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, than you may dispute our regular contract benefits decision under the OPM

disputed claim process (see section 8).

Flexible benefits option

The Plan provides a large case management program that seeks to provide alternatives for

improving the quality and cost effectiveness of care. The large case management program

focuses on catastrophic illnesses — for example, major head injury, high-risk infancy,

stroke and severe amputations. The large case management process begins when we are

notified that you or covered family member has experienced a specific illness or injury

with potential long-term effects or changes in lifestyle. Case Managers evaluate

individual needs, and the full range of treatment and financial exposures, from the onset of

a condition or illness to recovery or stabilization. They review the efforts of the health

care team and family with the goal of helping the patient return to pre-illness/injury

functioning or of lessening the burden of a chronic or terminal condition. Case Managers

provide the family with support and advice ranging from referral to family counseling. If

it is determined that involvement of a Case Manager would be both care- and cost-

effective, we will obtain the necessary authorization from the patient to proceed.

Throughout the process, we will maintain strict confidentiality.

Large Case Management

For information and assistance 24 hours a day, 7 days a week, access our automated

telephone AnswerLine at 212/501-4GHI (4444).

Customer Service

AnswerLine

If you have a question concerning Plan benefits or how to arrange for care, contact (212)

721-4962 (Hearing impaired — TDD) or you may write to us at Post Office Box 1701,

New York, NY 10023-9476 or contact our office nearest you. You may also contact the

Plan at its website at http://www.emblemhealth.com.

Services for deaf and

hearing impaired

The Plan provides an intensive case management program to identify and manage high

risk pregnancies as described in large case manangement above.

High risk pregnancies

We have a special network of hospitals that perform a broad range of cardiac care and

organ transplants. These centers are recognized leaders in their respective specialties and

their services are available to you at no out-of-pocket expense. Call GHI Managed Care

at least 10 days before the hospital admission to pre-certify coverage and for details on

how to use this program.

Centers of Excellence

As a GHI subscriber under the High Option Plan benefit package, you are not restricted to

just using members of our provider network. However, if you go outside the network,

your out-of-pocket expenses will increase significantly. You will receive 50% of our fee

schedule if you use a non-participating provider — you are responsible for the balance of

the provider’s charge. Also, unlike when you use a network provider, you are responsible

for paying the non-participating provider up front and filing a claim form with us for

reimbursement.

Travel benefit/ services

overseas

62 2018 GHI Health Plan High and Standard Option Section 5(h)

Section 5(i). High Option Point of Service benefits

High Option POS

High Option Point of Service (POS) Benefits

Facts about this Plan’s High Option POS benefits

Except for the benefits listed below, at your option, you may choose to obtain benefits covered by this Plan from non-

participating doctors and hospitals whenever you need care. Benefits not covered under the Point of Service option must be

obtained from participating providers.

The following benefits must be obtained from a participating provider.

•High-tech nursing and infusion therapy

•Skilled nursing care facility confinements

•Home health care services

•Prescription drugs

•Non-emergency inpatient hospital admissions

All other benefits covered by this Plan may be obtained from participating or non-participating providers.

Remember, only participating providers have agreed to accept the Plan’s allowance, except for any applicable copayments, as

payment in full. If you choose to receive covered services from non-participating or out-of-network providers, you will be

reimbursed at the POS level that in most cases is 50% of the Plan’s allowance.

Covered POS benefits are available whether the services are received within or outside the GHI Health Plan’s Service Area.

All non-emergency hospital admissions including inpatient admissions for maternity care and skilled nursing facilities must

be pre-certified.

For services received by non-participating or out of network providers there is a $500 Self Only, or $1000 Self Plus One; or

$1000 Self and Family calendar year deductible.

There is a $100 annual deductible for appliances, oxygen and equipment and $150 annual deductible for nursing services.

There is also a $20 copayment for ambulatory laboratory test and diagnostic X-rays performed at outpatient hospital or

ambulatory surgical center.

In most cases, the POS coinsurance is any amount in excess of 50% of the Plan’s fee schedule. The Plan’s fee schedule

is set at approximately 45% of the New York State Fair Health reimbursement rate. Members, when receiving POS

services, will be responsible for 50% of the Plan’s fee schedule plus any difference between our fee schedule and the

billed amount.

After your out-of-pocket expenses total $15,000 per person in any calendar year for covered services provided by a non-

participating provider, GHI will then pay catastrophic benefits at 100% of reasonable and customary charges as determined

by the Plan. Out-of-pocket expenses are calculated based upon the reasonable and customary charge for covered catastrophic

services. Covered catastrophic services include: 1) surgery, 2) administration of anesthesia, 3) chemotherapy and radiation

therapy, 4) covered in-hospital services and diagnostic services, and 5) maternity. However, expenses for the following

services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay coinsurance

and deductibles for these services:

•Home and office visits and related diagnostic services

•Nursing, appliances, oxygen and equipment

•Dental services

•Vision services

If you are in a true emergency situation, POS benefits are available within or outside the GHI’s Health Plan’s

service area.

63 2018 GHI Health Plan High Option POS Section 5(i)

High Option POS

Emergencies within the service area:

Benefits are available for care from non-participating providers in a medical emergency only if delay in reaching a Plan

provider would result in death, disability or significant jeopardy to your condition.

The Plan pays the emergency allowance for emergency care services to the extent the services would have been covered if

received from Plan providers.

You pay the emergency room cost sharing plus any charges that exceed the emergency allowance. If the emergency care is

provided by private physicians who are not hospital employees, you may receive a separate bill for these services, which will

be processed as a medical benefit.

Emergencies outside the service area:

Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen

illness.

The Plan pays full the emergency allowance for emergency care services to the extent the services would have been covered

if received from Plan providers.

You pay the emergency room cost sharing any difference between our emergency allowance and billed amount for a non-

participating provider. If the emergency care is provided by private physicians who are not hospital employees, you may

receive a separate bill for these services, which will be processed as a medical benefit.

What is covered

- Emergency care at a doctor’s office or an urgent care center.

- Ambulance service (see page 51).

- Emergency care as an outpatient or inpatient at a hospital, including doctors’ services.

If the medical/surgical care received from non-participating providers is not due to a medical emergency as defined above,

the Plan will pay 50% of its fee schedule. Follow-up care after an emergency is covered in full only if received from

participating providers.

64 2018 GHI Health Plan High Option POS Section 5(i)

Non-FEHB benefits available to Plan members

The benefits on this page are not part of the FEHB contract or premium and you cannot file an FEHB disputed claim

about them. Fees you pay for these services do not count toward FEHB deductibles or catastrophic protection out-of-pocket

maximums. These programs and materials are the responsibility of the Plan, all appeals must follow their guidelines. For

additional information contact the Plan at (877) 842-3625 or visit their website at www.emblemhealth.com

Health Club Memberships - At some clubs, Plan members get the lowest publicly available rate. Others offer a 10%

discount.

Weight Loss Services- Save on programs including Jenny Craig.

Vitamins and Natural Supplements - Order online and save 45%.

Registered Dietitians - Save 25% on nutrition counseling from credentialed dietitians.

Vision Affinity Discount Program - Receive discounts up to 20% at participating Davis Vision Centers.

Massage Therapy - Save up to 25% on therapeutic massage.

Acupuncture Therapy - Save up to 25% on acupuncture therapy.

Laser Vision Care- Save as much as 25% on laser vision correction.

Services included in EmblemHealth’s Healthy Discounts program are available only through participating vendors.

These discount programs are not health care benefits and we do not insure them.

For more about these services, visit www.emblemhealth.com/goodhealth.

Benefits on this page are not part of the FEHB contract.

65 2018 GHI Health Plan Section 5 Non-FEHB Benefits available to Plan members

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

The exclusions in this section apply to all benefits. There may be other exclusions and limitations listed in Section 5 of this

brochure. Although we may list a specific service as a benefit, we will not cover it unless it is medically necessary to

prevent, diagnose, or treat your illness, disease, injury or condition. For information on obtaining prior approval for

specific services, such as transplants, see Section 3 When you need prior approval for certain services.

We do not cover the following:

•Services, drugs, or supplies you receive while you are not enrolled in this Plan;

•Services, drugs, or supplies that are not medically necessary;

•Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;

•Experimental or investigational procedures, treatments, drugs or devices (see specifics regarding transplants);

•Services, drugs, or supplies related to abortions except when the life of the mother would be endangered if the fetus were

carried to term or when the pregnancy is the result of an act of rape or incest;

•Services or supplies you receive from a provider or facility barred from the FEHB Program;

•Services, drugs or supplies you receive without charge while in active military service.

66 2018 GHI Health Plan Section 6

Section 7. Filing a claim for covered services

This Section primarily deals with post-service claims (claims for services, drugs or supplies you have already received. See

Section 3 for information on pre-service claims procedures (services, drugs or supplies requiring prior Plan approval),

including urgent care claims procedures. When you see Plan physicians, receive services at Plan hospitals and facilities, or

obtain your prescription drugs at Plan pharmacies, you will not have to file claims. Just present your identification card and

pay your copayment, coinsurance, or deductible.

You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these providers

bill us directly. Check with the provider. If you need to file the claim, here is the process:

In most cases, providers and facilities file claims for you. Physicians must file the form

CMS-1500, Health Insurance Claim Form. Facilities will file the UB-04 form. For claims

questions and assistance, contact us at (877)842-3625 or at our website at www.

emblemhealth.com.

When you must file a claim, - such as for services you received outside the Plan's service

area- submit it on the CMS-1500 or a claim form that includes all the following shown

below. Bills and receipts should be itemized and show:

• Covered member’s name, date of birth, address, phone number and ID number

• Name and address of the physician or facility that provided the service or supply

• Dates you received the services or supplies

• Diagnosis

• Type of each service or supply

• The charge for each service or supply

• A copy of the explanation of benefits, payments, or denial from any primary payor --

such as the Medicare Summary Notice (MSN), and

• Receipts, if you paid for your services.

Note: Canceled checks, cash register receipts or balance due statements are not

acceptable substitute for itemized bills.

Submit your claims to:

EmblemHealth

P.O. Box 3000

New York, New York 10116-3000

Medical and hospital

benefits

For drugs obtained at a non-participating pharmacy in an emergency call GHI Pharmacy

Services at 1-877-444-3614 to obtain a claim form.

Prescription drugs

Send us all of the documents for your claim as soon as possible. You must submit the

claim by December 31 of the year after the year you received the service. If you could not

file on time because of Government administrative operations or legal incapacity, you

must submit your claim as soon as reasonably possible. Once we pay benefits, there is a

five year limitation on the re-issuance of uncashed checks.

Deadline for filing your

claim

We will notify you of our decision within 30 days after we receive your post-service

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

additional 15 days for review and we will notify you before the expiration of the original

30-day period. Our notice will include the circumstances underlying the request for the

extension and the date when a decision is expected.

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.

Post-service claims

procedures

67 2018 GHI Health Plan Section 7

If you do not agree with our initial decision, you may ask us to review it by following the

disputed claims process detailed in Section 8 of this brochure.

You may designate an authorized representative to act on your behalf for filing a claim or

to appeal claims decisions to us. For urgent care claims, a health care professional with

knowledge of your medical condition will be permitted to act as your authorized

representative without your express consent. For the purposes of this section, we are also

referring to your authorized representative when we refer to you.

Authorized

Representative

If you live in a county where at least 10 percent of the population is literate only in a non-

English language (as determined by the Secretary of Health and Human Services), we will

provide language assistance in that non-English language. You can request a copy of your

Explanation of Benefits (EOB) statement, related correspondence, oral language services

(such as telephone customer assistance), and help with filing claims and appeals

(including external reviews) in the applicable non-English language. The English versions

of your EOBs and related correspondence will include information in the non-English

language about how to access language services in that non-English language.

Any notice of an adverse benefit determination or correspondence from us confirming an

adverse benefit determination will include information sufficient to identify the claim

involved (including the date of service, the health care provider, and the claim amount, if

applicable), and a statement describing the availability, upon request, of the diagnosis and

procedure codes.

Notice Requirements

68 2018 GHI Health Plan Section 7

Section 8. The disputed claims process

You may appeal directly to the Office of Personnel Management (OPM) if we do not follow required claims processes. For

more information about situations in which you are entitled to immediately appeal to OPM, including additional

requirements not listed in Sections 3, 7 and 8 of this brochure, please visit www.emblemhealth.com.

Please follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on

your post service claim (a claim where services, drugs or supplies have already been provided). In Section 3 If you disagree

with our pre-service claim decision, we described the process you need to follow if you have a claim for services, referrals,

drugs or supplies that must have prior plan approval, such as inpatient hospital admissions.

To help you prepare your appeal, you may arrange with us to review and copy, free of charge, all relevant materials and Plan

documents under our control relating to your claim, including those that involve any expert review(s) of your claim. To make

your request, please contact our Customer Service Department by writing EmblemHealth Customer Service, 55 Water Street,

New York, NY 10041 calling (877)842-3625.

Our reconsideration will take into account all comments, documents, records, and other information submitted by you

relating to the claim, without regard to whether such information was submitted or considered in the initial benefit

determination.

When our initial decision is based (in whole or in part) on a medical judgement (i.e., medical necessity, experimental/

investigational), we will consult with a health care professional who has appropriate training and experience in the field of

medicine involved in the medical judgement and who was not involved in making the initial decision.

Our reconsideration will not take into account the initial decision. The review will not be conducted by the same person, or

his/her subordinate, who made the initial decision.

We will not make our decisions regarding hiring, compensation, termination, promotion, or other similar matters with respect

to any individual (such as a claims adjudicator or medical expert) based upon the likelihood that the individual will support

the denial of benefits.

Disagreements between you and the CDHP or HDHP fiduciary regarding the administration of an HSA or HRA are not

subject to the disputed claims process.

Step Description

Ask us in writing to reconsider our initial decision. You must:

a) Write to us within 6 months from the date of our decision; and

b) Send your request to us at: GHI Customer Service Department, 441 Ninth Avenue, New York, NY 10001;

and

c) Include a statement about why you believe our initial decision was wrong, based on specific benefit

provisions in this brochure; and

d) Include copies of documents that support your claim, such as physicians' letters, operative reports, bills,

medical records, and explanation of benefits (EOB) forms.

e) Include your email address (optional for members), if you would like to receive our decision via email.

Please note that by giving us your email, we may be able to provide our decision more quickly.

We will provide you, free of charge and in a timely manner, with any new or additional evidence considered,

relied upon, or generated by us or at our direction in connection with your claim and any new rationale for

our claim decision. We will provide you with this information sufficiently in advance of the date that we are

required to provide you with our reconsideration decision to allow you a reasonable opportunity to respond

to us before that date. However, our failure to provide you with new evidence or rationale in sufficient time

to allow you to timely respond shall not invalidate our decision or reconsideration. You may respond to that

new evidence or rationale at the OPM review stage described in step 4.

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

69 2018 GHI Health Plan Section 8

a) Pay the claim or

b) Write to you and maintain our denial or

c) Ask you or your provider for more information.

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

then decide within 30 more days.

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

was due. We will base our decision on the information we already have. We will write to you with our

decision.

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

You must write to OPM within:

• 90 days after the date of our letter upholding our initial decision; or

• 120 days after you first wrote to us -- if we did not answer that request in some way within 30 days; or

• 120 days after we asked for additional information.

Write to OPM at:United States Office of Personnel Management, Insurance Operations, Health Insurance II,

1900 E Street, NW, Washington, D.C. 20415-3620.

Send OPM the following information:

• A statement about why you believe our decision was wrong, based on specific benefit provisions in this

brochure;

• Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical

records, and explanation of benefits (EOB) forms;

• Copies of all letters you sent to us about the claim;

• Copies of all letters we sent to you about the claim;

• Your daytime phone number and the best time to call; and

• Your email address, if you would like to receive OPM's decision via email. Please note that by providing

your email address, you may receive OPM's decision more quickly.

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

which claim.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your

representative, such as medical providers, must include a copy of your specific written consent with the

review request. However, for urgent care claims, a health care professional with knowledge of your medical

condition may act as your authorized representative without your express consent. However, for urgent care

claims, a health care professional with knowledge of your medical condition may act as your authorized

representative without your express consent.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline because

of reasons beyond your control.

OPM will review your disputed claim request and will use the information it collects from you and us to

decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no other

administrative appeals.

If you do not agree with OPM’s decision, your only recourse is to sue. If you decide to file a lawsuit, you

must file the suit against OPM in Federal court by December 31 of the third year after the year in which you

received the disputed services, drugs, or supplies or from the year in which you were denied precertification

or prior approval. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim

decision. This information will become part of the court record.

70 2018 GHI Health Plan Section 8

You may not file a lawsuit until you have completed the disputed claims process. Further, Federal law

governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record

that was before OPM when OPM decided to uphold or overturn our decision. You may recover only the

amount of benefits in dispute.

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death

if not treated as soon as possible), and you did not indicate that your claim was a claim for urgent care, then call us at (800)

223-9870. We will expedite our review (if we have not yet responded to your claim); or we will inform OPM so they can

quickly review your claim on appeal. You may call OPM's Health Insurance II at (202) 606-3818 between 8 a.m. and 5 p.m.

Eastern Time.

Please remember that we do not make decisions about plan eligibility issues. For example, we do not determine whether you

or a dependent is covered under this plan. You must raise eligibility issues with your Agency personnel/payroll office if you

are an employee, your retirement system if you are an annuitant or the Office of Worker's Compensation Programs if you are

receiving Worker's Compensation benefits.

71 2018 GHI Health Plan Section 8

Section 9. Coordinating benefits with Medicare and other coverage

You must tell us if you or a covered family member has coverage under any other health

plan or has automobile insurance that pays health expenses without regard to fault. This is

called “double coverage.”

When you have double coverage, one plan normally pays its benefits in full as the primary

payor and the other plan pays a reduced benefit as the secondary payor. We, like other

insurers, determine which coverage is primary according to the National Association of

Insurance Commissioners' (NAIC) guidelines. For more information on NAIC rules

regarding the coordinating of benefits, visit our website at www.emblemhealth.com.

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

When we are the secondary payor, we will determine our allowance. After the primary

plan pays, we will pay what is left of our allowance, up to our regular benefit. We will not

pay more than our allowance.

When you have other

health coverage

TRICARE is the health care program for eligible dependents of military persons, and

retirees of the military. TRICARE includes the CHAMPUS program. CHAMPVA

provides health coverage to disabled Veterans and their eligible dependents. IF TRICARE

or CHAMPVA and this Plan cover you, we pay first. See your TRICARE or CHAMPVA

Health Benefits Advisor if you have questions about these programs.

Suspended FEHB coverage to enroll in TRICARE or CHAMPVA: If you are an

annuitant or former spouse, you can suspend your FEHB coverage to enroll in one of

these programs, eliminating your FEHB premium. (OPM does not contribute to any

applicable plan premiums.) For information on suspending your FEHB enrollment,

contact your retirement office. If you later want to re-enroll in the FEHB Program,

generally you may do so only at the next Open Season unless you involuntarily lose

coverage under TRICARE or CHAMPVA.

TRICARE and

CHAMPVA

We do not cover services that:

• You (or a covered family member) need because of a workplace-related illness or

injury that the Office of Workers’ Compensation Programs (OWCP) or a similar

Federal or State agency determines they must provide; or

• OWCP or a similar agency pays for through a third-party injury settlement or other

similar proceeding that is based on a claim you filed under OWCP or similar laws.

Once OWCP or similar agency pays its maximum benefits for your treatment, we will

cover your care.

Workers’ Compensation

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

Suspended FEHB coverage to enroll in Medicaid or a similar State-sponsored

program of medical assistance: If you are an annuitant or former spouse, you can

suspend your FEHB coverage to enroll in one of these State programs, eliminating your

FEHB premium. For information on suspending your FEHB enrollment, contact your

retirement office. If you later want to re-enroll in the FEHB Program, generally you may

do so only at the next Open Season unless you involuntarily lose coverage under the State

program.

Medicaid

We do not cover services and supplies when a local, State, or Federal government agency

directly or indirectly pays for them.

When other Government

agencies are responsible

for your care

Our right to pursue and receive subrogation and reimbursement recoveries is a condition

of, and a limitation on, the nature of benefits or benefit payments and on the provision of

benefits under our coverage.

When others are

responsible for injuries

72 2018 GHI Health Plan Section 9

If you have received benefits or benefit payments as a result of an injury or illness and you

or your representatives, heirs, administrators, or assignees receive payment from any party

that may be liable, a third party's insurance policies, your own insurance policies, or a

workers' compensation program or policy, you must reimburse us out of that payment.

Our right of reimbursement extends to any payment received by settlement, judgment, or

otherwise.

We are entitled to reimbursement to the extent of the benefits we have paid or provided in

connection with your injury or illness. However, we will cover the cost of treatment that

exceeds the amount of the payment you received.

Reimbursement to us out of the payment shall take first priority (before any of the rights

of any other parties are honored) and is not impacted by how the judgment, settlement, or

other recovery is characterized, designated, or apportioned. Our right of reimbursement is

not subject to reduction based on attorney fees or costs under the "common fund" doctrine

and is fully enforceable regardless of whether you are "made whole" or fully compensated

for the full amount of damaged claimed.

We may, at our option, choose to exercise our right of subrogation and pursue a recovery

from any liable party as successor to your rights.

If you do pursue a claim or case related to your injury or illness, you must promptly notify

us and cooperate with our reimbursement or subrogation efforts.

Some FEHB Plans already cover dental and vision services. When you are covered by

more than one vision/dental plan, coverage provided under your FEHB plan remains as

your primary coverage. FEDVIP coverage pays secondary to that coverage. When you

enroll in a dental and/or vision plan on BENEFEDS.com or by phone 1-877-888-3337

(TTY 1-877-889-5680), you will be asked to provide information on your FEHB Plan so

that your plans can coordinate benefits. Providing your FEHB information may reduce

your out-of-pocket cost.

When you have Federal

Employees Dental and

Vision Insurance Plan

(FEDVIP) coverage

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial

that is conducted in relation to the prevention, detection, or treatment of cancer or other

life-threatening disease or condition and is either Federally funded; conducted under an

investigational new drug application reviewed by the Food and Drug administration; or is

a drug trial that is exempt from the requirement of an investigational new drug

application.

If you are a participant in a clinical trial, this health plan will provide related care as

follows, if it is not provided by the clinical trial:

• Routine care costs – costs for routine services such as doctor visits, lab tests, x-rays

and scans, and hospitalizations related to treating the patient’s cancer, whether the

patient is in a clinical trial or is receiving standard therapy.

• Extra care costs – costs related to taking part in a clinical trial such as additional tests

that a patient may need as part of the trial, but not as part of the patient’s routine care.

We do not cover these costs.

• Research costs – costs related to conducting the clinical trial such as research

physician and nurse time, analysis of results, and clinical tests performed only for

research purposes. We do not cover these costs.

Clinical Trials

When you have Medicare

Medicare is a Health Insurance Program for:

• People 65 years of age and older;

• Some people with disabilities, under 65 years of age; and

• What is Medicare?

73 2018 GHI Health Plan Section 9

• People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a

transplant).

Medicare has four parts:

• Part A (Hospital Insurance). Most people do not have to pay for Part A. If you or your

spouse worked for at least 10 years in Medicare-covered employment, you should be

able to qualify for premium free part A insurance. (If you were a Federal employee at

any time both before and during January 1983, you will receive credit for your Federal

employment before January 1983.) Otherwise, if you are age 65 or older, you may be

able to buy it. Contact 800-MEDICARE (800-633-4227), (TTY 877-486-2048) for

more information.

• Part B (Medical Insurance). Most people pay monthly for Part B. Generally, part B

premiums are withheld from your monthly Social Security check or your retirement

check.

• Part C (Medicare Advantage). You can enroll in a Medicare Advantage plan to get

your Medicare benefits. We offer a Medicare Advantage plan. Please review the

information on coordinating benefits with Medicare Advantage plans on the next page.

• Part D (Medicare prescription drug coverage). There is a monthly premium for Part D

coverage. Before enrolling in Medicare Part D, please review the important disclosure

notice from us about the FEHB prescription drug coverage and Medicare. The notice

is on the first inside page of this brochure. For people with limited income and

resources, extra helping paying for a Medicare prescription drug plan is available. For

more information about this extra help, visit the Social Security Administration online

at www.socialsecurity.gov, or call them at 800-722-1213 (TTY 877-486-2048).

The decision to enroll in Medicare is yours. We encourage you to apply for Medicare

benefits 3 months before you turn age 65. It's easy. Just call the Social Security

Administration toll-free number 800-772-1213 (TTY 800-325-0778) to set up an

appointment to apply. If you do not apply for one or more Parts of Medicare, you can still

be covered under the FEHB Program.

If you can get premium-free Part A coverage, we advise you to enroll in it. Most Federal

employees and annuitants are entitled to Medicare Part A at age 65 without cost. When

you don't have to pay premiums for Medicare Part A, it makes good sense to obtain the

coverage. It can reduce your out-of-pocket expenses as well as costs to the FEHB, which

can help keep FEHB premiums down.

Everyone is charged a premium for Medicare Part B coverage. The Social Security

Administration can provide you with premium and benefit information. Review the

information and decide if it makes sense for you to buy the Medicare Part B coverage. If

you do not sign up for Medicare Part B when you are first eligible, you may be charged a

Medicare Part B late enrollment penalty of a 10 % increase in premium for every 12

months you are not enrolled. If you didn't take Part B at age 65 because you were covered

under FEHB as an active employee (or you were covered under your spouse's group

health insurance plan and he/she was an active employee), you may sign up for Part B

(generally without an increased premium) within 8 months from the time you or your

spouse stop working or are no longer covered by the group plan. You also can sign up at

any time while you are covered by the group plan.

• Should I enroll in

Medicare?

74 2018 GHI Health Plan Section 9

If you are eligible for Medicare, you may have choices in how you get your health care.

Medicare Advantage is the term used to describe the various private health plan choices

available to Medicare beneficiaries. The information in the next few pages shows how we

coordinate benefits with Medicare, depending on whether you are in the Original

Medicare Plan or a private Medicare Advantage plan.

The Original Medicare Plan (Original Medicare) is available everywhere in the United

States. It is the way everyone used to get Medicare benefits and is the way most people

get their Medicare Part A and Part B benefits now. You may go to any doctor, specialist, or

hospital that accepts Medicare. The Original Medicare Plan pays its share and you pay

your share.

All physicians and other providers are required by law to file claims directly to Medicare

for members with Medicare Part B, when Medicare is primary. This is true whether or not

they accept Medicare.

When you are enrolled in Original Medicare along with this plan, you still need to follow

the rules in this brochure for us to cover your care.

Claims process when you have The Original Medicare Plan – You will probably not

need to file a claim form when you have both our Plan and the Original Medicare Plan.

When we are the primary payor, we processes your claim first.

When Original Medicare is the primary payor, Medicare processes your claim first. In

most cases, your claims will be coordinated automatically and we will then provide

secondary benefits for covered charges. You will not need to do anything. To find out if

you need to do something about filing your claims, call us at (877) 842-3625, or access

our website at www.emblemhealth.com

We waive some costs if the Original Medicare Plan is your primary payor – We will

waive some out-of-pocket costs, as follows:

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

professionals. If you are enrolled in Medicare Part B, we will waive the copay for

office visits and deductible and coinsurance for durable medical equipment.

Under the Standard Option benefit package, care by non-participating providers for

routine care is not covered even if Medicare is primary. To get full maximum use of your

Standard Option package you must use GHI's participating provider network for services.

Please review the following table it illustrates your cost share if you are enrolled in

Medicare Part B. Medicare will be primary for all Medicare eligible services. Members

must use providers who accept Medicare’s assignment.

• The Original

Medicare Plan (Part

A or Part B)

75 2018 GHI Health Plan Section 9

Benefit

Description

Member Cost

without

Medicare

Member Cost

without

Medicare

Member Cost

with Medicare

Part B

Member Cost

with Medicare

Part B

Benefit

Description

High Option Standard

Option

High Option Standard

Option

Deductible $0 $0 $0 $0

Out-of- Pocket

Maximum

$6,850 Self

Only/

$13,700 Self

Plus One or

Self and Family

$6,850 Self

Only/

$13,700 Self

Plus One or

Self and Family

$6,850 Self

Only/

$13,700 Self

Plus One or

Self and Family

$6,850 Self

Only/

$13,700 Self

Plus One or

Self and Family

Primary Care

Physician

$20 $40 $0 $0

Specialist $20 $40 $0 $0

Inpatient

Hospital

$200 copay per

day for the first

three days per

admission

$250 copay per

day for the first

three days per

admission

$0 $0

Outpatient

Hospital

$175 $175 $0 $0

Rx Level 1 -$20

Level 2 -$45

Level 3 - $85

Level 4 – 25%

up to $200 per

script Specialty

(30 day supply)

Level 1 -$15

Level 2 -$50

Level 3 - $100

Level 4 – 25%

up to $200 per

script Specialty

(30 day supply)

Level 1 -$20

Level 2 -$45

Level 3 - $85

Level 4 – 25%

up to $200 per

script Specialty

(30 day supply)

Level 1 -$15

Level 2 -$50

Level 3 - $100

Level 4 – 25%

up $200 per

script Specialty

(30 day supply)

Rx – Mail

Order (90 day

supply)

Level 1 -$40

Level 2 - $90

Level 3 - $125

Level 1 - $40

Level 2 - $125

Level 3 - $170

Level 1 - $40

Level 2 - $90

Level 3 - $125

Level 1 - $40

Level 2 - $125

Level 3 - $170

You can find more information about how our plan coordinates benefits with Medicare in

(name of plan publication) at www.emblemhealth.com

You must tell us if you or a covered family member has Medicare coverage, and let us

obtain information about services denied or paid under Medicare if we ask. You must also

tell us about other coverage you or your covered family members may have, as this

coverage may affect the primary/secondary status of this Plan and Medicare.

• Tell us about your

Medicare coverage

If you are eligible for Medicare, you may choose to enroll in and get your Medicare

benefits from a Medicare Advantage plan. These are private health care choices (like

HMOs and regional PPOs) in some areas of the country. To learn more about Medicare

Advantage plans, contact Medicare at 800-MEDICARE (800 632-4227), (TTY

877-486-2048) or at www.medicare.gov

If you enroll in a Medicare Advantage plan, the following options are available to you:

• Medicare Advantage

(Part C)

76 2018 GHI Health Plan Section 9

This plan or another plan’s Medicare Advantage plan: You may enroll in another

plan’s Medicare Advantage plan and also remain enrolled in our FEHB plan. We will still

provide benefits when your Medicare Advantage plan is primary, even out of the Medicare

Advantage plan’s network and/or service area. However, we will not waive any of our

copayments, coinsurance, or deductibles.

Under the Standard Option benefit package, care by non-participating providers for

routine care is not covered even if Medicare Advantage is primary. To get full maximum

use of your Standard Option package you must use GHI's participating provider network

for services.

If you enroll in a Medicare Advantage Plan, tell us. We will need to know whether you are

in the Original Medicare Plan or in a Medicare Advantage plan so we can correctly

coordinate benefits with Medicare.

Suspended FEHB coverage to enroll in a Medicare Advantage plan: If you are an

annuitant or former spouse, you can suspend you FEHB coverage to enroll in a Medicare

Advantage plan, eliminating your FEHB premium. (OPM does not contribute to your

Medicare Advantage plan premium.) For information on suspending your FEHB

enrollment, contact your retirement office. If you later want to re-enroll in the FEHB

Program, generally you may do so only at the next Open Season unless you involuntarily

lose coverage or move our of the Medicare Advantage plan’s service area.

When we are the primary payor, we process the claim first. If you enroll in Medicare Part

D and we are the secondary payor, we will review claims for your prescription drug costs

that are not covered by Medicare Part D and consider them for payment under the FEHB

plan.

• Medicare prescription

drug coverage (Part

77 2018 GHI Health Plan Section 9

Medicare always makes the final determination as to whether they are the primary payor. The following chart illustrates

whether Medicare or this Plan should be the primary payor for you according to your employment status and other factors

determined by Medicare. It is critical that you tell us if you or a covered family member has Medicare coverage so we can

administer these requirements correctly. (Having coverage under more than two health plans may change the order of

benefits determined on this chart.)

Primary Payor Chart

A. When you - or your covered spouse - are age 65 or over and have Medicare and you... The primary payor for the

individual with Medicare is...

Medicare This Plan

1) Have FEHB coverage on your own as an active employee

2) Have FEHB coverage on your own as an annuitant or through your spouse who is an

annuitant

3) Have FEHB through your spouse who is an active employee

4) Are a reemployed annuitant with the Federal government and your position is excluded from

the FEHB (your employing office will know if this is the case) and you are not covered under

FEHB through your spouse under #3 above

5) Are a reemployed annuitant with the Federal government and your position is not excluded

from the FEHB (your employing office will know if this is the case) and...

• You have FEHB coverage on your own or through your spouse who is also an active

employee

• You have FEHB coverage through your spouse who is an annuitant

6) Are a Federal judge who retired under title 28, U.S.C., or a Tax Court judge who retired

under Section 7447 of title 26, U.S.C. (or if your covered spouse is this type of judge) and

you are not covered under FEHB through your spouse under #3 above

7) Are enrolled in Part B only, regardless of your employment status

for Part B

services

for other

services

8) Are a Federal employee receiving Workers' Compensation disability benefits for six months

or more

B. When you or a covered family member...

1) Have Medicare solely based on end stage renal disease (ESRD) and...

• It is within the first 30 months of eligibility for or entitlement to Medicare due to ESRD

(30-month coordination period)

• It is beyond the 30-month coordination period and you or a family member are still entitled

to Medicare due to ESRD

2) Become eligible for Medicare due to ESRD while already a Medicare beneficiary and...

• This Plan was the primary payor before eligibility due to ESRD (for 30 month

coordination period)

• Medicare was the primary payor before eligibility due to ESRD

3) Have Temporary Continuation of Coverage (TCC) and...

• Medicare based on age and disability

• Medicare based on ESRD (for the 30 month coordination period)

• Medicare based on ESRD (after the 30 month coordination period)

C. When either you or a covered family member are eligible for Medicare solely due to

disability and you...

1) Have FEHB coverage on your own as an active employee or through a family member who

is an active employee

2) Have FEHB coverage on your own as an annuitant or through a family member who is an

annuitant

D. When you are covered under the FEHB Spouse Equity provision as a former spouse

*Workers' Compensation is primary for claims related to your condition under Workers' Compensation.

78 2018 GHI Health Plan Section 9

Section 10. Definitions of terms we use in this brochure

January 1 through December 31 of the same year. For new enrollees, the calendar year

begins on the effective date of their enrollment and ends on December 31 of the same

year.

Calendar year

An approved clinical trial includes a phase I, phase II, phase III, or phase IV clinical trial

that is conducted in relation to the prevention, detection, or treatment of cancer or other

life-threatening disease or condition and is either Federally funded; conducted under an

investigational new drug application reviewed by the Food and Drug Administration; or is

a drug trial that is exempt from the requirement of an investigational new drug

application.

If you are a participant in a clinical trial, this health plan will provide related care as

follows, if it is not provided by the clinical trial.

• Routine care costs – costs for routine services such as doctor visits, lab tests, x-rays

and scans, and hospitalizations related to treating the patient’s cancer, whether the

patient is in a clinical trial or is receiving standard therapy

• Extra care costs – costs related to taking part in a clinical trial such as additional tests

that a patient may need as part of the trial, but not as part of the patient’s routine care

• Research costs – costs related to conducting the clinical trial such as research

physician and nurse time, analysis of results, and clinical tests performed only for

research purposes. These costs are generally covered by the clinical trials. This plan

does not cover these costs.

Clinical Trials Cost