SmarterCare PPO Plan

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, copayments, and plan maximums. 

The SmarterCare PPO medical plan covers:

• 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
• 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 smear;
• Chiropractic care, if medically necessary;
• Prostate specific antigen (PSA);
• 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;
• 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 Anthem, travel and lodging benefits are covered separately for transplants at a Blue Distinction Center for Transplant (BDCT)
• 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.

The following services and supplies are not covered by the SmarterCare PPO medical plan:

• 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.

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 Anthem.

• Anthem Machine Readable Files

If there is no in-network provider available near your home (within 25 miles), the Plan will cover an out-of-network provider at the in-network level. You must call Anthem to arrange for a network deficiency accommodation.

The out-of-network provider may send you a bill for the difference between their billed charges and Anthem's maximum allowed amount. You are not
responsible for this amount. If this happens, please call Anthem so they can reprocess the claim.

If you are enrolled in the SmarterCare PPO medical plan, you have access to prescription drug coverage through Capital Rx.

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 coinsurance.

For annual formulary updates, refer to the 2026 National Preferred Formulary. 

Prescription Drug Program Plan Design

Prescription drug costs under the SmarterCare PPO plan vary by drug tier. Generic drugs are covered with a fixed copay, while preferred brand and non-preferred brand drugs are subject to coinsurance. You do not need to meet the deductible before the plan begins covering your prescriptions – you will only pay the applicable copay or coinsurance. Note that prescription copays and coinsurance do not count towards meeting your deductible.

Below is the plan design for the prescription drug program.

There’s no deductible for certain preventive drugs and lower costs for select maintenance preventive drugs. Refer to the 2026 Preventive Drug List for medications that are included.

Rx Smart Save

Rx Smart Save is a smart, easy-to-use program that helps you save money on prescription medications. It identifies safe, effective, and lower-cost alternatives that are covered by your plan. When a more affordable option is available, you’ll receive a notification through the Capital Rx app or web portal. To take advantage of the savings, you'll need to talk to your provider about the alternative and get a new prescription. Refer to the flyer for additional information. 

Prior Authorization

Prior Authorization is a feature of your prescription drug plan designed to ensure the safe, effective, and appropriate use of certain prescription drugs. These specific prescription drugs require your doctor to provide information for you to gain approval before the prescription drug is covered. This process helps make sure you receive the right prescription 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 using the most cost-effective drug therapy for a medical condition first. If the initial medication does not work, your doctor can request approval for a more costly drug therapy.

Quantity Limits

Quantity Limits help ensure prescription drugs are used safely and effectively. For certain prescription drugs, there may be a maximum amount that will be covered over a certain time period based on doctor recommendations, FDA guidelines and safety standards. This helps prevent taking too much of a medication and supports proper treatment.

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, a participant must meet the deductible and pay the applicable coinsurance. For office visits, the participant is responsible for the copay which is not subject to the deductible. Other outpatient services (habilitative treatment, partial hospitalization) are covered at 100% with no deductible.
• For inpatient care, a participant must meet the deductible and pay the applicable coinsurance.

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.

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.

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

Under the SmarterCare PPO medical plan, you pay as follows:

• In-Network Inpatient: 20% after deductible
• In-Network Outpatient: Office Visits - $30 copay, no deductible; 

If you choose to see an out-of-network provider without a network deficiency accommodation, you could end up paying significantly more than you would with an in-network provider. Anthem only pays up to its maximum allowed amount and out-of-network providers can bill you for the difference
between their billed charges and what Anthem covers, which is often a large gap.

Also, note that most doctor charges (except mental health and substance use disorder services), are reimbursed based on 150% of Medicare rates, which are typically much lower than the provider's billed amount. The doctor may bill you the difference. As a result, your out-of-pocket costs can be
much higher. To avoid unexpected bills and to keep your expenses down, it's best to stay in-network whenever possible.

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. 

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 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.