Priority Health priorityhealth.com/fehb Customer Service 800-446-5674 2019 A Health Maintenance Organization (High and Standard Option) This plan’s health coverage qualifies as minimum essential coverage and meets the minimum value standard for the benefits it IMPORTANT provides. This plan is accredited. See page 12. • Rates: Back Cover • Changes for 2019: Page 16 Serving: The Lower Peninsula of Michigan • Summary of benefits: Page 96 Enrollment in this Plan is limited. You must live or work in our geographic service area to enroll. See page 12 for service area. Enrollment codes for this Plan: LE1 High Option - Self Only LE3 High Option - Self Plus One LE2 High Option - Self and Family LE4 Standard Option - Self Only LE6 Standard Option - Self Plus One LE5 Standard Option - Self and Family RI 73-884 Important Notice from Priority Health About Our Prescription Drug Coverage and Medicare The Office of Personnel Management (OPM) has determined that the Priority Health 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 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 through December 7) to enroll in Medicare Part D. Medicare’s Low Income Benefits For people with limited income and resources, extra help paying for a Medicare prescription drug plan is available. Information regarding this program is available through the Social Security Administration (SSA) online at www. socialsecurity.gov, or call the SSA at 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 ...................................................................................................................................................................................8 Section 1. How This Plan Works ................................................................................................................................................13 Section 2. Changes for 2019 .......................................................................................................................................................16 Section 3. How You Get Care .....................................................................................................................................................17 Section 4 Your Costs for Covered Services ................................................................................................................................25 Section 5 High and Standard Option Benefits ............................................................................................................................27 Section 5 High and Standard Option Benefits Overview ...........................................................................................................29 Section 5(a) Medical Services and Supplies Provided by Physicians and Other Health Care Professionals .............................30 Diagnostic and treatment Services ....................................................................................................................................30 Lab, X-ray and other diagnostic tests ................................................................................................................................31 Preventive care, adult ........................................................................................................................................................31 Preventive care, children ...................................................................................................................................................34 Maternity care ...................................................................................................................................................................36 Family planning ................................................................................................................................................................37 Infertility services .............................................................................................................................................................38 Allergy care .......................................................................................................................................................................39 Treatment therapies ...........................................................................................................................................................39 Physical and occupational therapies .................................................................................................................................40 Speech therapy ..................................................................................................................................................................40 Autism Spectrum Disorder services ..................................................................................................................................40 Hearing services (testing, treatment, and supplies) ...........................................................................................................40 Vision services (testing, treatment, and supplies) .............................................................................................................41 Foot Care ...........................................................................................................................................................................41 Orthopedic and prosthetic devices ....................................................................................................................................41 Durable medical equipment (DME) ..................................................................................................................................42 Home health services ........................................................................................................................................................43 Chiropractic care ...............................................................................................................................................................43 Alternative integrative holistic health care .......................................................................................................................44 Educational classes and programs .....................................................................................................................................44 Section 5(b) Surgical and Anesthesia Services Provided by Physicians and Other Health Care Professionals .........................45