Healthy Focus Medical Plans

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 listed below are subject to any applicable annual deductibles, coinsurance, co-payments, and plan maximums. See Comparing the Healthy Focus Medical Plans for more detail.

The Healthy Focus medical plans cover:

• Physician's office visits;
• Other physician's services;
• Emergency or urgent care;
• Professional ambulance service to transport a person from the place where he or she is 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 physical exams (Preventive Care) includes one exam every calendar year.
• 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 for treatment of a disease or injury, to alleviate chronic pain given, or as a form of anesthesia in connection with a surgery;
• Diagnostic lab work and X-rays - routine and non-routine - up to plan maximum;
• 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 - one diagnostic test per calendar year for ages 21 and older;
• Chiropractic care, if medically necessary;
• Prostate specific antigen (PSA) age 40+ ;
• 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), zygote intrafallopian tube transfer (ZIFT) and non-injectable prescription drug therapy used specifically for infertility, 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;
• Skilled nursing care expenses made by an R.N. or L.P.N. or a nursing agency for skilled nursing care, which includes visiting nursing care from an R.N. or L.P.N. for up to four hours for the purpose of performing skilled nursing tasks, and 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 and visiting nursing care is not adequate. Private duty nursing benefit is combined with home health care benefits with a maximum of 100 visits per year;
• Spinal disorders;
• Treatment of the mouth, jaws and teeth due to a medical condition affecting the teeth, mouth, jaws, jaw joints or supporting tissue (including bones, muscles and nerves) based on medical, not dental, necessity;
• 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;
• Sex-change 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;
• Listed transplants are covered only if performed by the Administrator's contracted Institutes (or Centers) of Excellence (IOE) facilities. List of IOE Procedure and Treatment types - heart transplant, lung transplant, liver transplant, bone marrow transplant, heart/lung transplant, kidney transplant, pancreas transplant, kidney/pancreas transplant.
• For IOE procedure and treatments - The Plan will pay for transportation and lodging between participant's home and the IOE to receive services in connection with IOE procedure or treatment. Travel and lodging expenses for IOE patient and one companion/parent/guardian traveling with the IOE patient must be approved in advance by Administrator.
  • 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 maximum of $10,000 per 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.

The following services and supplies are not covered by the Leidos self-insured medical plans:

• Treatment for the mouth, jaws and teeth when an injury or illness is dental in nature, 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 reasonable and customary limits as determined by the applicable Claims 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;
• Illness or injury due to an act of war (whether declared or undeclared) or an injury sustained while the participant is in military service for any country at war;
• 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;
• Therapy, supplies or counseling for sexual dysfunctions or inadequacies that do not have a physiological or organic basis;
• 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; and
• Medical expense not specifically described in the plans.

If you are enrolled in one of the Healthy Focus medical plans, you have access to prescription drug coverage through Express Scripts.

For annual formulary updates, refer to the 2021 Preferred Drug List. Effective April 1, 2021, Express Scripts (ESI) will exclude 29 additional products from the National Preferred Formulary and address lower-cost alternatives. Refer to the additional list of exclusions for details. 

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.

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 less costly.
• Brand formulary drugs are on a preferred list of prescriptions (called a formulary) due to significant discounts negotiated with the drug manufacturer and/or proven effectiveness
• Brand non-formulary drugs are brand-name drugs that do not have a generic equivalent and are not included on the list of preferred drugs. Brand-name drugs that are not on the formulary require the highest copayment, since these drugs are the most costly to the plan.

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. 

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 2021 Preventive Drug List for medications that are included.

Looking for pricing for your medication? Please visit the Express Scripts enrollment site.

Prior Authorization

Prior authorization is a feature of your prescription benefits plan that helps ensure the appropriate use of selected prescription drugs. Certain prescription drugs require your doctor to get approval before they're covered. This process helps make sure you receive the right medicine in the correct dose, which is very important if you're taking a specialty drug. These medicines are only approved for specific conditions and usually require keeping in close touch with your doctor. Prior authorization takes the extra step to watch specialty drugs.

Read the FAQs to learn more.

Step Therapy

Step Therapy is an approach intended to control the costs and risks posed by certain prescription drugs. It begins with a drug therapy for a medical condition with the most cost-effective and safest drug therapy and progresses to other more costly or risky drug therapies only if necessary. 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 Express Scripts mail service 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 Express Scripts 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 Express Scripts (ESI) mail order or Walgreens will not count towards the deductible or out-of-pocket maximum. Additionally, participants will still pay penalties after they meet their out-of-pocket maximum.

Read the FAQs to learn more.

Patient Assurance Program

If you are enrolled in a Healthy Focus medical plan you will have access to the Patient Assurance Program (PAP) administered by Express Scripts. With this program, when you fill a prescription for a select diabetes product as part of the PAP, you will pay no more than $75 for a 90-day prescription for certain insulin products at retail or mail order. In other words, your out‑of‑pocket amount is capped and significantly reduced at the point‑of‑sale for both home delivery and in-network retail pharmacies. Any copay amount paid will apply to your annual out-of-pocket maximum only. Select diabetes medications are included within the following categories:

• Preferred insulins
• Preferred non-insulin diabetes medications (DPP-4 inhibitors, GLP-1 agonists and SGLT2 inhibitors)

Note: all prescription drug fills for maintenance medications are subject to the terms of the Smart90 program.

Refer to the Drug List to view the prescriptions included in the program. 

Propeller

If you are enrolled in a Healthy Focus medical plan and have asthma or COPD, Express Scripts (ESI) has partnered with Propeller to offer a FREE program to help you manage your breathing.

Propeller is a digital health tool that’s clinically proven to reduce the use of rescue inhalers and to help you have more days without symptoms.

• Download the Propeller app to your phone
• Get your inhaler sensors in the mail and sync with the app
• The app learns about your breathing, builds your personalized profile and provides:
  • Reminders to help you stay on track
  • A record of your medication use
  • Help determining your triggers
  • Tips to help you breathe easier
  • Progress reports you can share with your healthcare provider

Log in to your Express Scripts account at express-scripts.com/healthsolutions to see if you are eligible
for the Propeller program.

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 must call Aetna to receive information and guidance on how to locate a network provider or participants can search for a provider on the Aetna website. If a participant elects to use an out-of-network provider, the participant will be responsible for additional out-of-pocket costs.

When inpatient care is necessary, the participant must notify Aetna and obtain authorization in advance, whether he or she is using Aetna or an out-of-network provider.

If an emergency occurs, and it is not possible to get advance authorization, the participant must notify Aetna 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 Aetna regarding an emergency admission, regardless of whether he or she is in a Aetna or non-contracting facility.

Participants receive the highest plan benefits for mental health and substance abuse treatment by using network providers:

• For 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
• For inpatient 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 Aetna count toward the annual out-of-pocket maximums for the Healthy Focus plans.

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% after deductible out-of-network
• Healthy Focus Essential Plan: 50% after deductible out-of-network
• Healthy Focus Advantage Plan: 50% after deductible out-of-network
• Healthy Focus Premier Plan: 0% after deductible out-of-network

Deductibles and coinsurance for mental health and substance abuse services received through Aetna count toward the deductible and annual out-of-pocket maximums for the Healthy Focus plans.

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.

No payment will be made by Aetna for the following care, services or supplies:

• Educational rehabilitation or treatment of learning disabilities, regardless of the setting in which such services are provided;
• Educational/academic testing and services;
• Residential Coverage for Wilderness Programs or Military Schools;
• Residential treatment facilities, that do not meet Aetna or Anthem 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 Aetna or Anthem as medically necessary;
• Psychological testing, except when considered medically necessary by Aetna;
• Prescription drugs;
• Private duty nursing, except when precertified by Aetna as medically necessary;
• Treatment or consultations provided via telephone;
• 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 Aetna with a lien against such claim for damages or relief in a form and manner satisfactory to Aetna;
• 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.