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, up to 3 visits per day, 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;
• 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.
• Under Anthem, transplants are covered at the in-network level only if performed at an Anthem Blue Distinction Center for Transplants (BDCT) or Center of Medical Excellence (CME).
• 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 Leidos self-insured medical plans::

• For gene-based, cellular and other innovative therapies (GCIT), the following are not covered services unless you receive prior written approval:
  • All associated services when GCIT services are not covered. Examples include:
    • Infusion
    • Lab
    • Radiology
    • Anesthesia
    • Nursing services
• Growth/height care
  • A treatment, device, drug, service or supply to increase or decrease height or alter the rate of growth
  • Surgical procedures, devices and growth hormones to stimulate growth
• Maintenance care
  • Care made up of services and supplies that maintain, rather than improve, a level of physical or mental function, except for habilitation therapy services
• Medical supplies – outpatient disposable. Any outpatient disposable supply or device. Examples of these include:
  • Sheaths
  • Bags
  • Elastic garments
  • Support hose
  • Bandages
  • Bedpans
  • Home test kits not related to diabetic testing
  • Splints
  • Neck braces
  • Compresses
  • Other devices not intended for reuse by another patient
• Missed appointments
  • Any cost resulting from a canceled or missed appointment
• Nutritional support except for coverage of “low protein modified food product” that are specifically formulated to have less than one gram of protein per serving and are intended to be used under the direction of a physician for the dietary treatment of any inherited metabolic disease. Low protein modified food products do not include foods that are naturally low in protein.
  • Covered services include formula and low protein modified food products ordered by a physician for the treatment of phenylketonuria or an inherited disease of amino and organic acids.
• Any food item, including:
  • Infant formulas
  • Nutritional supplements
  • Vitamins
  • Prescription vitamins
  • Medical foods
  • Other nutritional items
• Other non-covered services
  • Services you have no legal obligation to pay
  • Services that would not otherwise be charged if you did not have the coverage under the plan
• Other primary payer
  • Payment for a portion of the charges that Medicare or another party is responsible for as the primary payer
• Personal care, comfort or convenience items
  • Any service or supply primarily for your convenience and personal comfort or that of a third party
• Routine exams and preventive services and supplies
  • Routine physical exams, routine eye exams, routine dental exams, routine hearing exams and other preventive services and supplies
• Services not permitted under applicable state or local laws
  • Some state or local laws restrict the scope of health care services that a provider may render. In such cases, the plan will not cover such health care services. Note that in some cases the plan may provide travel benefits for services affected by this exclusion.
• Services provided by a family member
  • Services provided by a spouse, civil union partner, domestic partner, parent, child, stepchild, brother, sister, in-law, or any household member
• Services, supplies and drugs received outside of the United States
  • Non-emergency medical services, outpatient prescription drugs or supplies received outside of the United States. They are not covered even if they are covered in the United States under this booklet.
• Strength and performance
  • Services, devices and supplies such as drugs or preparations designed primarily to enhance your strength, physical condition, endurance or physical performance
• Therapies and tests
  • 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
• Tobacco cessation
  • Any treatment, drug, service or supply to stop or reduce smoking or the use of other tobacco products or to treat or reduce nicotine addiction, dependence or cravings, including, medications, nicotine patches and gum unless recommended by the United States Preventive Services Task Force (USPSTF). This also includes:
    • Counseling, except as specifically provided as a covered service
    • Hypnosis and other therapies
    • Medications, except as specifically provided as a covered service
    • Nicotine patches
    • Gum
• Treatment in a federal, state, or governmental entity
  • Any care in a hospital or other facility owned or operated by any federal, state or other governmental entity unless coverage is required by applicable laws
• Voluntary sterilization
  • Reversal of voluntary sterilization procedures, including related follow-up care
• Services for the following based on categories, conditions, diagnoses or equivalent terms as listed in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association
  • Stay in a facility for treatment for dementia and amnesia without a behavioral disturbance that necessitates mental health treatment
  • School and/or education service, including special education, remedial education, wilderness treatment programs, or any such related or similar programs
  • Services provided in conjunction with school, vocation, work or recreational activities
  • Transportation
  • Sexual deviations and disorders except as specifically covered under the Plan
• Work related illness or injuries
  • Coverage available to you under workers’ compensation or a similar program under local, state or federal law for any illness or injury related to employment or self-employment. Important note: A source of coverage or reimbursement is considered available to you even if you waived your right to payment from that source. You may also be covered under a workers’ compensation law or similar law. If you submit proof that you are not covered for a particular illness or injury under such law, then that illness or injury will be considered “non-occupational” regardless of cause.

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.

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 and Appeals Review Procedure Under ERISA in the Plan Information section.

Participants may submit out-of-network claims online at www.anthem.com by clicking on Claims & Payments, then Claim Submission Center. You may also submit claims via the Anthem Sydney Health app by clicking on Claims, then Claim Submission Center. 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: P.O. Box 105187, Atlanta, GA 30348-5187.

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

Prescription drug coverage under the SmarterCare CDHP and the SmarterCare PPO Medical Plans is provided through Capital Rx, a Judi Health Company. Prescription drugs are covered when they are purchased from an in-network retail pharmacy or through Costco pharmacies.

Types of Prescriptions Available

The amount a participant pays for a prescription depends on the type of drug the covered participant purchases. 

• 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. To view the current formulary drugs list, refer to the 2026 National Preferred Formulary.
• 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.

Prescription drug formularies are subject to change. For up-to-date formulary information, participants should visit the Capital Rx microsite (https://enrollment.cap-rx.com/?client=leidos), log in to their Capital Rx account via the website (https://app.cap-rx.com/login) or mobile app, or contact Capital Rx 

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. The deductible does not apply to prescription drugs under this plan, allowing for more predictable budgeting for medications. Note that prescription copays and coinsurance amounts do not count toward the medical plan deductible.

Below is the plan design for the prescription drug plan.

^{1 Up to a 30-Day Supply 
2 Includes Mail Order & Retail 90-Day Supply}
 

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. 

Short-Term Medications

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 may visit the Capital Rx microsite (https://enrollment.cap-rx.com/?client=leidos), log in to their Capital Rx account via the website (https://app.cap-rx.com/login) or mobile app, or contact Capital Rx Customer Service at 833-202-5926 for assistance.

Maintenance Medications

Participants who take long-term maintenance medications (generally a prescription for more than 30 days) are required to fill these medications in a 90-day supply. If maintenance medications are filled in quantities of less than a 90-day supply, beginning with the third fill, the participant will be responsible for the full cost of the medication. These costs will not apply toward the deductible or out-of-pocket maximum, if applicable.

A 90-day supply can be obtained at any in-network retail pharmacy that supports 90-day fills or through Costco Mail Order. Through Costco Mail Order, prescriptions are mailed directly to the participant’s home for added convenience. 

If using Costco Mail Order, one of the following options may be used to request refills of current prescriptions or to send new prescriptions:

• Mail: Visit rx.costco.com and access the patient account to request a refill or submit a new prescription. Paper prescriptions may be mailed to: Costco Pharmacy, 6801 Seaway Blvd., Suite A-2, Everett, WA 98203.
• E-prescribe: The prescriber may electronically send the prescription to Costco Pharmacy Mail Order #1748, zip code 98203.
• Fax: The prescriber may fax your prescription to 1-877-258-9584. Faxed prescriptions must be sent directly from the provider’s office and include patient information.

Refer to the FAQs for instruction on how to fill a mail order prescription. 

A Costco membership is not required to use Costco Pharmacy Services. Both members and non-members can purchase prescription medications at Costco pharmacies whether in-store or online. 

Specialty Medications

For participants managing complex or chronic health conditions, Costco Specialty Pharmacy provides personalized support, including access to pharmacists and nurses, as well as assistance with insurance coordination and prior authorizations.

Prescriptions may be e-prescribed to Costco Specialty Pharmacy #1710, zip code 53717 or faxed to 855-213-0125. The prescriber should include the participant’s contact information. Additional steps may be required if prior authorization applies.

A Costco Specialty Pharmacy representative will contact the participant to arrange delivery. Participants may also call Capital Rx at 833-202-5926 and follow the specialty pharmacy prompts to confirm receipt or request refills.

Specialty prescriptions can be managed through the Costco Specialty Pharmacy Portal at https://specialty.rx.costco.com/login or by calling Capital Rx at 833-202-5926 and following the prompts for home-delivered medications.

Refer to the Specialty Pharmacy Guide for additional information. 

A Costco membership is not required to use Costco Pharmacy Services. Both members and non-members can purchase prescription medications at Costco pharmacies whether in-store or online. 

Prior Authorization

Prior Authorization is a feature of the 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.