Healthy Focus Medical Plans
Knowing how to get the most from your health plan matters. Making smart moves can save you time and money.
User Guide
For help using your Healthy Focus medical plan, view the Healthy Focus User Guide. The guide includes a refresher on how your plan works and provides important tips, advice and resources.
Plan Administrator
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Aetna Inc. administers the Leidos Consumer Directed Healthcare Plans (CDHP).
Product Name: Aetna Open Access Plans — Aetna Choice POS II network
Leidos Group Number: 698685
Aetna Customer Service Phone (Aetna One Advisor): 800-843-9126
Submit Claims to:
Aetna Inc
P.O. Box 981106
El Paso, TX 79998-1106Website: www.aetna.com
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The plans for Dynetics are administered by Anthem who will provide administrative services, including member services and medical claims processing.
Product Name: Anthem Bluecard PPO Network
Leidos Group Number: 201108
Anthem Customer Service Phone: 833-549-1179
Submit Claims to:
Anthem Inc
P.O. Box 105187
Atlanta, GA 30348Website: www.anthem.com
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If you are enrolled in one of the Healthy Focus medical plans, you have access to prescription drug coverage through Express Scripts (ESI). Prescription drugs are covered when they are purchased from an in-network retail pharmacy or through the Express Scripts pharmacy mail order program.
Retail Pharmacies
A participant who needs to take medication for a short period of time (up to 30 days) should have their prescription filled at an in-network retail pharmacy.
To locate an in-network retail pharmacy, participants can log onto the Express Scripts website or call the ESI Customer Service at 877-223-4721.
Mail Order
A participant who needs to use a long-term, maintenance medication (generally a prescription for more than 30 days) can fill his or her prescription through the ESI pharmacy mail order program. Through the ESI mail order program, participants can receive up to a 90-day supply of medication and prescriptions are mailed directly to the participant's home.
Mail Order Address:
Express Scripts
P.O. Box 650322
Dallas, TX 75265-0322Participants may fill prescriptions by sending a prescription and mail order pharmacy form to ESI. For refills, participants can submit requests directly to ESI:
- Through the Express Scripts web site
- By phone 877-223-4721; or
- By returning the mail order pharmacy order form; or
- Through the ESI Mobile App
How the Healthy Focus Medical Plans Work
The Healthy Focus Medical Plans are Consumer Directed Health Plans (CDHP). For all non- preventive care, the plans pay the majority of the cost for in-network coverage after you meet the annual deductible. Your share is a percentage called coinsurance. In-network preventive care is covered 100%, no deductible. Once you meet the out-of-pocket maximum, the plan pays 100% of covered costs. All the CDHP plans feature a Health Savings Account (HSA) to help save and budget for eligible healthcare expenses, with tax-free advantages.
Precertification
If a participant is enrolled in the Healthy Focus Plan, precertification is required for the following types of services: hospitalization, skilled nursing care, home healthcare, hospice care, residential treatment facility or partial hospitalization for mental health disorders or substance abuse, bariatric surgery, gene therapy, gender affirming treatment, stays in a rehabilitation facility, comprehensive infertility services, Advanced Reproductive Technology (ART) services, injectables (immunoglobulins, growth hormones, etc.), kidney dialysis, knee surgery, wrist surgery, outpatient back surgery, private duty nursing, sleep studies, applied behavioral analysis, cosmetic and reconstructive surgery, transcranial magnetic stimulation and non-emergency transportation by airplane.
For in-network services, the in-network providers are responsible for obtaining pre-certification. For out-of-network services, the participant is responsible for obtaining precertification.
The Plan Administrator will certify the medical necessity and length of any applicable hospital confinement for inpatient care. Under Aetna, inpatient precertification must be requested at least 14 days before admission. Under Anthem, pre-service review must be requested at least the day prior to the admission. The Plan Administrator will work with a participant’s doctor to ensure that the hospitalization is appropriate, medically necessary, and timely, and then let the participant know the number of days for which admission has been certified.
If an emergency occurs, and it is not possible to get advance authorization, the participant or provider must notify the Plan Administrator of all inpatient treatment within 48 hours of the admission. The participant or provider must contact the Plan Administrator regarding an emergency admission, regardless of whether the facility is in-network or out-of-network.
If the participant fails to obtain the required precertification, benefits may be reduced or the Plan may not pay any benefits.
Paying for Medical Care
Here's how the Healthy Focus medical plan options pay for covered care:
- For most care (including doctor office visits and lab work), the Healthy Focus plans pay the majority of the cost for coverage, after you meet the annual deductible. Your share is a percentage called coinsurance.
- Preventive care is covered 100 percent, no deductible.
- Once you reach the annual out-of-pocket maximum, the plan pays 100 percent of covered costs.
HealthEquity administers the HSA to pay eligible expenses with pre-tax dollars — and when you enroll in a Healthy Focus plan, the Company may contribute to your HSA. The HSA contribution will be based on an employee's annual salary and the coverage level elected for medical coverage.
Deductible
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For the 2024 Plan Year:
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Out-of-Pocket Maximum |
For the 2024 Plan Year:
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HealthEquity administers the HSA to pay eligible expenses with pre-tax dollars — and when you enroll in a Healthy Focus plan, the Company may contribute to your HSA. The HSA contribution will be based on an employee's annual salary and the coverage level elected for medical coverage.
Coverage
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Services or supplies must be considered medically necessary by the Plan Administrator, be delivered for the treatment of illness or injury, and be performed or prescribed by a licensed physician to be covered by the Leidos self-insured medical plans. The services listed below are subject to any applicable annual deductibles, coinsurance, co-payments, and plan maximums.
The Healthy Focus medical plans cover:
- Physician's office visits;
- Other physician's services;
- Emergency or urgent care;
- Professional ambulance service to transport a member from the place where the member injured or stricken by disease to the first hospital where treatment is given;
- Hearing aids up to $2,500 allowance per pair, every three years
- Hospital expenses including:
- Inpatient hospital expenses: Charges for room and board, and other hospital services and supplies for a person confined as a full-time inpatient;
- Outpatient hospital expenses: Charges for hospital services and supplies for a person who is not confined as a full-time inpatient;
- Skilled Nursing Facility care services including room and board up to the semi-private room rate and applicable services and supplies (up to 60 days maximum limit per confinement)
- Routine preventive physical exams (subject to age and visit limitations under Aetna)
- Immunizations;
- Home health care expenses when the charge is made by a home health care agency, the care is given under a home health care plan, and the care is given to a person in his or her home for part-time or intermittent care by an R.N. (or L.P.N. when an R.N. is not available); part-time or intermittent home health aide patient care services; and physical, occupational and speech therapy. There is a maximum of 100 visits covered in a plan year and a visit equates to up to four hours by a home health aide;
- Hospice care expenses at an inpatient facility or outpatient care. Outpatient hospice care is covered for part-time or intermittent care by an R.N. (or L.P.N. when an R.N. isn't available) up to eight hours a day, medical social services under the direction of a physician, psychological and dietary counseling, consultation or case management services by a physician, and physical and occupational therapy. This includes charges for bereavement counseling if it is given to the person's immediate family, is given during three months following the person's death, and is directly related to the person's death;
- Drugs and medicines which by law need a physician's prescription, including medically necessary weight control drugs;
- Acupuncture when performed by a physician or certified acupuncturist; limited to 10 visits per year;
- Diagnostic lab work and X-rays - routine and non-routine - frequency limits may apply;
- X-ray, radium and radioactive isotope therapy;
- Anesthetics and oxygen;
- Rental of durable medical or surgical equipment, including repair of such equipment or replacement when it is proved that it is needed due to a change in the person's physical condition or it is likely to cost to purchase a replacement than to repair existing equipment;
- Maternity;
- Mammograms;
- Routine pap smears (subject to age and frequency guidelines under Aetna);
- Chiropractic care, if medically necessary;
- Prostate specific antigen (PSA) (subject to age and frequency guidelines under Aetna);
- Infertility treatment for a female employee, the wife or registered domestic partner of a Leidos employee, including in vitro fertilization, embryo transfer, gamete intrafallopian tube transfer (GIFT), and zygote intrafallopian tube transfer (ZIFT) will be covered up to $5,000 per lifetime. The following conditions must be met:
- The female participant must have been unable to conceive after having unprotected intercourse for one year or more (six months or more if over the age of 35);
- The female participant must have been unable to attain a successful pregnancy through less costly treatment covered under the plan;
- The female participant must have FSH levels which are less than 19 miU on day 3 of her menstrual cycle;
- The procedure cannot involve surrogates; and
- The procedure must be performed at a medical facility that conforms to generally accepted medical standards.
- Artificial insemination;
- Voluntary sterilization;
- Private duty nursing from an R.N. or L.P.N. for up to eight hours if the person's condition requires skilled nursing services. Private duty nursing benefit is combined with home healthcare benefits with a maximum of 100 visits per year. each visit by a nurse is considered one visit;
- Spinal disorders;
- Treatment of the mouth, jaws and teeth due to a congenital birth defect or injury due to an accident. When provided by a physician, dentist and hospital, the plan covers the below. These procedures cannot be associated with the removal, replacement or repair of teeth unless due to an accident or congenital birth defect:
- Cutting out cysts, tumors or other diseased tissues
- Cutting into gums and tissues of the mouth
- TMJ or malocclusion involving the joints or muscles (includes medically necessary, non-dental, bite blocks, splints, arch bars, and occlusal guards);
- Physical therapy, speech therapy and occupational therapy determined to be medically necessary, up to a combined limit of 60 visits per calendar year;
- Prosthetic devices that temporarily or permanently replaces all or part of an external body part lost or impaired as a result of illness, injury or congenital defects;
- Gender affirmation surgery or any treatment of gender identity disorders;
- Wigs for hair loss due to injury, disease or treatment of disease, including costs for repair or replacement.
- Autism diagnosis and Applied Behavioral Analysis (ABA) Therapy, including habilitative, physical, occupational, speech, behavioral and ABA therapy for autism spectrum disorder, no age, visit or dollar limits;
- Under Aetna, transplants are covered at the in-network level only if performed by the Administrator's contracted Institutes (or Centers) of Excellence (IOE) facilities. This includes heart transplant, lung transplant, liver transplant, bone marrow transplant, heart/lung transplant, kidney transplant, pancreas transplant, kidney/pancreas transplant.
- Autism diagnosis and Applied Behavioral Analysis (ABA) Therapy, including habilitative physical, occupational, speech, behavioral and ABA therapy for autism spectrum disorder; no age, visit or dollar limits.
- Mental Health and Substance related disorders treatment.
- Treatment under an approved clinical trial only when the member has cancer or a terminal illness.
- Diabetic services, supplies and equipment.
- Infant formula and low protein modified food products ordered by a physician to treat phenylketonuria or an inherited disease of amino and organic acids.
- Obesity surgery for a morbidly obese patient.
- Travel and lodging in cases of network deficiency: if covered services are not available from a network provider within 100 miles of your home, the following travel and lodging expenses are covered under the plan:
- U.S. domestic travel and lodging expenses for you and one companion, to travel from your home to receive the covered services from a network provider (coach class air fare, train or bus travel are examples of covered services)
- The maximum lodging benefit is $50 per person per night, up to a total maximum lodging benefit of $100
- Total maximum travel and lodging benefit is $2,500 per year
- To be eligible for travel and lodging reimbursement, you must first confirm with the plan administrator that a network provider is not available within 100 miles of your home by calling the toll-free number on your ID card
- Under Aetna, this travel and lodging benefit is covered separately for:
- Services coordinated through the Institutes of Excellence™, Institutes of Quality, National Medical Excellence® or Gene-based, Cellular and other Innovative Therapies (GCIT) programs
- Under Anthem, travel and lodging benefits are covered separately for transplants at a Blue Distinction Center for Transplant (BDCT)
- Under Aetna, the claim form must be submitted to within 6 months of the date of service
- U.S. domestic travel and lodging expenses for you and one companion, to travel from your home to receive the covered services from a network provider (coach class air fare, train or bus travel are examples of covered services)
- Under Aetna: IOE transplant procedures/treatments and Gene-Based, Cellular and Innovative Therapies (GCIT)
- The Plan will pay for transportation and lodging between participant’s home and the IOE or designated GCIT provider to receive services in connection with the procedure or treatment. Travel and lodging expenses for the patient and one companion/parent/guardian traveling with the patient must be approved in advance by the Administrator. When pre- authorized, the Plan will reimburse a maximum of $50 per person per night for lodging expenses.
- The Plan will reimburse travel and lodging expenses incurred up to a maximum of $10,000 per transplant/episode of care. The Plan will pay expenses incurred during a period which begins on the day a participant becomes an IOE patient and ends on the earlier of one year after the day the procedure is performed or the date the IOE patient ceases to receive any service from the IOE in connection with the procedure.
- This travel and lodging benefit is available if the IOE or the designated GCIT provider is not available within 100 miles of the participant’s home.
- Under Anthem, the plan will pay for travel and lodging expenses to a Blue Distinction Center for Transplant (BDCT) facility if the patient lives more than 100 miles from the transplant facility. The maximum lodging allowance is $50 per person for the patient and one companion, up to a total of $100 per night, The maximum travel and lodging benefit is $10,000 per transplant.
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The following services and supplies are not covered by the Leidos self-insured medical plans:
- Except in cases of congenital birth defects or injury due to an accident, treatment for the mouth, jaws and teeth are excluded, including restorative dental and/or surgical treatment of the mouth or jaw, including but not limited to:
- Non-accident related diagnosis and treatment of teeth and their supporting structures;
- Treatment relating to or secondary to treatment of dental caries (cavities);
- Extraction of a diseased or decayed tooth or for surgical removal or impacted teeth; and
- Root canal therapy, periodontal surgery or X-rays and other diagnostic tests;
- Cosmetic surgery, unless required because of an accidental injury that takes place while the participant is covered by the plan, or the congenital malformation of a child born to the participant or his or her spouse or registered domestic partner while the participant has dependent coverage under the plan;
- Charges above the recognized charge limits/maximum allowed amount as determined by the applicable Plan Administrator;
- Custodial care;
- Eye care exams and eyeglasses;
- Orthopedic shoes or other devices to support the feet;
- Experimental, investigational or educational treatment or services as determined by the Claims Administrator;
- Treatment for accidents related to employment or an illness covered under Workers' Compensation or similar laws;
- Assistant surgeon services when the services of an assistant surgeon are not medically necessary for the surgical procedure;
- Stay in a facility for treatment and dementia and amnesia without a behavioral disturbance that necessitates mental health treatment;
- Skilled nursing care that does not require the education, training and technical skills of an R.N. or L.P.N. (such as transportation, meal preparation, charting of vital signs), any private duty nursing care given while the person is an inpatient in a hospital or other health care facility, care provided to help a person in the activities of daily life, such as bathing, feeding, personal grooming, dressing, getting in and out of bed or a chair, or toileting or care provided solely for skilled observation. Any service provided solely to administer oral medicines except where applicable law requires that such medicines be administered by a R.N. or L.P.N;
- Foot treatment for:
- Weak, strained, flat, unstable or unbalanced feet; metatarsalgia; or bunions, except open cutting operations; and
- Corns, calluses or toenails, except the removal of nail roots and medically necessary services prescribed by a doctor (M.D. or D.O.) in the treatment of metabolic or peripheral-vascular disease;
- Services, treatment, education testing or training related to learning disabilities or developmental delays;
- Care furnished mainly to provide a surrounding free from exposure that can worsen the participant's illness or injury;
- Treatments involving:
- Bioenergetic therapy;
- Carbon dioxide therapy;
- Megavitamin therapy;
- Primal therapy;
- Psychodrama;
- Rolfing; or
- Vision perception training;
- Treatment of covered health care providers who specialize in the mental health care field and who receive treatment as part of their training in that field;
- Services of a resident doctor or intern rendered in that capacity;
- Education or special education or job training whether or not given in a facility that also provides medical or psychiatric treatment;
- Career, social adjustment, pastoral or financial counseling;
- Speech therapy except for loss of speech, or speech impairment or developmentally delayed speech due to a diagnosed disease, injury or congenital defect;
- Reversal of a sterilization procedure;
- Medical services performed or provided by a close relative;
- Services of "standby" surgeons;
- Services received before coverage begins or after coverage ends;
- Charges that participants are not legally required to pay or charges that would not have been made if the plans were not available;
- Charges above any maximum amounts shown;
- Convenience or personal care services, such as use of a telephone or television;
- Blood, blood plasma, synthetic blood, blood derivatives or substitutes (e.g. the provision of blood to the hospital other than blood derived clotting factors, any related services such as processing and storage, the service of blood donors);
- Growth/height care (e.g. surgical procedures, devices and growth hormones to stimulate growth);
- Any cost resulting from missed appointments;
- Payment for charges that Medicare or another party is responsible for as the primary payer;
- Non-emergency medical services received outside of the United States;
- Therapies and tests including full body CT scans; hair analysis; hypnosis and hypnotherapy; massage therapy (except when used for physical therapy treatment); sensory or hearing and sound integration therapy; and
- Medical expense not specifically described in the plans.
- Except in cases of congenital birth defects or injury due to an accident, treatment for the mouth, jaws and teeth are excluded, including restorative dental and/or surgical treatment of the mouth or jaw, including but not limited to:
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Health plan price transparency helps consumers know the cost of a covered item or service before receiving care. As required under the Transparency in Coverage Rule of the 2021 Consolidated Appropriations Act (CAA), plan sponsors must publish machine-readable files that provide pricing information for covered services based on negotiated payment rates for in-network providers and historical allowed amounts for out-of-network providers. See below for a link to the machine-readable files provided by Aetna.
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If you are enrolled in one of the Healthy Focus medical plans, you have access to prescription drug coverage through Express Scripts.
Types of Prescriptions Available
The amount a participant pays for a prescription depends on the type of drug purchased.
- Generic drugs have the same chemical composition and potency as brand-name equivalents, but are usually less costly.
- Brand formulary drugs are on a preferred list of prescriptions (called a formulary) because they are safe and effective and help to control costs.
- Brand non-formulary drugs are brand-name drugs that cost more than generic or preferred drugs and are not included on the list of preferred drugs (formulary). Brand-name drugs that are not on the formulary require the highest co-insurance.
For annual formulary updates, refer to the 2024 National Preferred Formulary (updated 07/01/2024).
Prescription drug formularies are subject to change. For up-to-date formulary information, participants should visit Express Scripts website or call at 1-877-223-4721.
Prescription Drug Program Plan Design
The chart below provides basic information for Network (in-network retail pharmacies and mail order) and Out-of-Network coverage.
Healthy Focus Basic Healthy Focus Essential Healthy Focus Advantage Healthy Focus Premier Out-of-Network Generic 50%
$5
$5
$0
Not Covered
Formulary (Preferred Brand) 50%
30%
30%
0%
Not Covered
Non-Formulary (Non-Preferred Brand) 50%
50%
50%
0%
Not Covered
Note: For non-preventive prescription drugs, you must meet the annual deductible before the plan pays the majority of the cost. There’s no deductible for certain preventive drugs and lower costs for select maintenance preventive drugs. Refer to the 2024 Preventive Drug List for medications that are included.
Looking for pricing for your medication? Please visit the Express Scripts enrollment site.
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Prior Authorization
Prior Authorization is a feature of the prescription drug plan that helps ensure the appropriate use of selected prescription medications. Certain prescription drugs require your doctor to provide information for you to gain approval before the drug is covered. This process helps make sure you receive the right medicine for your condition.
Read the FAQs to learn more.
Step Therapy
Step Therapy is an approach intended to control the costs of certain prescription drugs when lower cost drugs are available, such as a generic or lower-cost brand name. These drugs are proven to be safe and effective, as well as affordable. It begins by trying the most cost-effective drug therapy for a medical condition first. When patients don’t respond to the first-line medications, more costly drug therapies, typically brand name drugs, can be requested for coverage approval.
Here’s an example of step therapy:
- You try an over-the-counter medication for an allergy, but it doesn't control your symptoms.
- Your doctor prescribes a prescription drug that still doesn't give you relief.
- A third medication that's more expensive works well, but requires step therapy.
In this case, your prescription is covered if you've tried the first choice drugs.
Read the FAQs to learn more.
Smart90
With this program, you have two ways to get a 90-day supply of your long-term maintenance medication — drugs you take regularly for ongoing conditions. You can conveniently fill these prescriptions through the ESI mail order program or any Walgreens network pharmacy. Your copay/coinsurance for your 90-day supply of medication will be the same whether you fill your prescriptions through ESI home delivery or at a Walgreens network pharmacy.
Note: If you continue to fill 30-day supplies of your long-term medication after the first two fills, you will pay a penalty (100% of the prescription drug cost). Penalties paid for not filing prescriptions through ESI mail order or Walgreens will not count towards the deductible or out-of-pocket maximum. Additionally, penalties will be imposed after a covered member has met their out-of-pocket maximum.
Read the FAQs to learn more.
Mental Health & Substance Abuse
The Healthy Focus medical plans include mental health and substance abuse benefits. For more information on how the mental health and drug or alcohol treatment works, visit the sections below.
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The mental health and substance abuse benefits are network-based and give participants a choice when it comes to receiving mental health and substance abuse treatment:
- For outpatient care, the participant pays a coinsurance. When the participant uses a network provider, the plan pays 80% after deductible. If a participant uses an out-of-network provider, the plan pays 50% after deductible.
- For inpatient care, the participant pays a coinsurance. When the participant uses a network provider, the plan pays 80% after deductible. If a participant uses an out-of-network provider, the plan pays 50% after deductible.
Participants may call the Plan Administrator to receive information and guidance on how to locate a network provider or participants can search for a provider on the Plan Administrator's website. If a participant elects to use an out-of-network provider, the participant will be responsible for additional out-of-pocket costs.
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When inpatient care is necessary, the participant must notify the Plan Administrator and obtain authorization in advance, whether he or she is using an in-network or an out-of-network provider.
If an emergency occurs, and it is not possible to get advance authorization, the participant must notify the Plan Administrator of all inpatient treatment within 48 hours of the admission (or the next business day if the patient receives treatment on a weekend or holiday). The participant must contact the Plan Administrator regarding an emergency admission, regardless of whether he or she is in an in-network or non-contracting facility.
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Participants receive the highest plan benefits for mental health and substance abuse treatment by using network providers:
- For both inpatient and outpatient care, the member pays as follows:
- Healthy Focus Basic Plan: 50% after in-network deductible
- Healthy Focus Essential Plan: 35% after in-network deductible
- Healthy Focus Advantage Plan: 20% after in-network deductible
- Healthy Focus Premier Plan: 0% after in-network deductible
Deductibles and coinsurance for mental health and substance abuse services received through the Plan Administrator count toward the annual out-of-pocket maximums for the Healthy Focus plans.
- For both inpatient and outpatient care, the member pays as follows:
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If a participant chooses to use an out-of-network provider to obtain outpatient services, the plan pays a percentage of the cost as follows:
- Healthy Focus Basic Plan: 50% of recognized charge/maximum allowed amount after deductible
- Healthy Focus Essential Plan: 50% of recognized charge/maximum allowed amount after deductible
- Healthy Focus Advantage Plan: 50% of recognized charge/maximum allowed amount after deductible
- Healthy Focus Premier Plan: 0% recognized charge/maximum allowed amount after deductible
Deductibles and coinsurance for mental health and substance abuse services received through the Plan Administrator count toward the deductible and annual out-of-pocket maximums for the Healthy Focus plans.
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Services or supplies must be considered medically necessary by the Claims Administrator, be delivered for the treatment of illness or injury, and be performed or prescribed by a licensed physician to be covered by the Leidos self-insured medical plans. The services are subject to any applicable annual deductibles, coinsurance, and co-payments. See Comparing the Healthy Focus Medical Plans for more detail.
In addition to meeting all other conditions for coverage, the treatment must meet the following criteria:
- There is a written treatment plan prescribed and supervised by a behavioral health provider;
- This Plan includes follow-up treatment; and
- This Plan is for a condition that can favorably be changed.
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No payment will be made by the Plan Administrator for the following care, services or supplies:
- Educational services - any service or supply for education, training, retraining services or testing. This includes:
- Special education
- Remedial education
- Wilderness treatment program (whether or not the program is part of a residential treatment facility or otherwise licensed institution)
- Job training
- Job hardening programs
- Educational services, schooling or any such related or similar program including therapeutic programs within a school setting;
- Residential treatment facilities, that do not meet the Plan Administrator's medical necessity requirements;
- Custodial care
- Treatment for personal or professional growth development, or training or professional certification;
- Evaluations, consultations or therapy for educational or professional training or for investigational purposes relating to employment;
- Therapies which do not meet national standards for mental health professional practice;
- Experimental or investigational therapies;
- Court-ordered psychiatric or substance abuse treatment, except when certified by the Plan Administrator as medically necessary;
- Psychological testing, except when considered medically necessary by the Plan Administrator;
- Private duty nursing, except when pre-certified by the Plan Administrator as medically necessary;
- Services, treatment or supplies:
- Provided as a result of Worker's Compensation laws or similar legislation;
- Obtained through, or required by, any governmental agency or program whether federal, state or any subdivision thereof (exclusive of Medicaid/Medi-Cal); or
- Caused by the conduct or omission of a third-party for which the Member has a claim for damages or relief, unless the participant provides the Plan Administrator with a lien against such claim for damages or relief in a form and manner satisfactory to the Plan Administrator;
- Treatment or consultations provided by the member's parents, siblings, children or current or former spouse or domiciliary partner, in-law or any household member;
- Sexual therapy programs;
- Remedial education beyond evaluation and diagnosis of learning disabilities, education rehabilitation, academic education, and educational therapy for learning disabilities;
- Marital therapy;
- Treatment for caffeine or nicotine intoxication, withdrawal or dependence; or
- Stay in a facility for treatment for dementia and amnesia without a behavioral disturbance that necessitates mental health treatment.
- Educational services - any service or supply for education, training, retraining services or testing. This includes:
Filing Claims
If a participant receives medical care, mental health or substance abuse treatment from an out-of-network provider, he or she must pay the full cost of care, then file a claim for reimbursement. Most medical claim forms should be submitted to the Plan Administrator.
Aetna Members
Aetna out-of-network claims should be submitted on the Aetna claim form and mailed to:
Aetna Inc.
P.O. Box 981106
El Paso, TX 79998
Anthem Members
Participants may submit out-of-network claims online at www.anthem.com or through the Anthem Sydney Health app. Click on Claims, then Submit a Claim. Participants must attach receipts including provider name and address, National Provider Identifier (NPI), date of service, diagnosis code and CPT code with description.
Alternatively, participants may submit completed claim forms with documentation to:
Anthem
P.O. Box 105187
Atlanta, GA 30348-5187
If a participant has concerns about how a claim has been administered or wishes to appeal a claims decision, the participant may refer to information on relevant procedures available in the Claims Appeal and Appeals Review Procedure Under ERISA in the Plan Information section.
Health Savings Account
You can contribute pretax dollars to the HSA up to the annual IRS contribution limit. You can use the HSA to pay for eligible health care expenses — tax free! The dollars that you contribute will roll over from one year to the next so you can grow your HSA balance to pay for future health care expenses.