Leidos Healthy Focus Medical Plans

 
 

Benefits Summary Plan Description

Leidos Healthy Focus Medical Plans

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Leidos Healthy Focus Medical Plans

                                               

 

 


 

Plan Administrators

The Leidos Healthy Focus Medical Plans are administered by Aetna Inc. and Anthem Blue Cross.

Aetna Open Access Plans

Employees who live in these states/district are under the Aetna Open Access Plans — Aetna Choice POS II network, administered by Aetna Inc:

  • Arkansas
  • California
  • District of Columbia
  • Delaware
  • Idaho
  • Illinois
  • Iowa
  • Kansas
  • Maine
  • Maryland
  • Michigan
  • Minnesota
  • Missouri
  • Montana
  • Nebraska
  • Nevada
  • New Hampshire
  • New Jersey
  • New York
  • North Dakota
  • Oklahoma
  • Oregon
  • Pennsylvania
  • South Dakota
  • Vermont
  • Virginia
  • West Virginia
  • Wisconsin
  • Wyoming

 

 

 

 

 

 

 

Product Name: Aetna Open Access Plans — Aetna Choice POS II network

Leidos Group Number: 698685

Aetna Customer Service Phone: 800-843-9126

Submit Claims to:

Aetna Inc
P.O. Box 14089
Lexington, KY 40512-4089

Web site: Aetna

Mail Order: Express Scripts

Mail Order Address:

Express Scripts
P.O. Box 650322
Dallas, TX 75265-0322

Participants may fill prescriptions by sending a prescription and mail order pharmacy form to Express Scripts. For refills, participants can submit requests directly to Express Scripts:

  • Through the Express Scripts web site
  • By phone 877-223-4721; or
  • By returning the mail order pharmacy order form.

 

Blue Card PPO Network

Employees who live in these states/commonwealth are under the Blue Card PPO network, administered by Athem Blue Cross:

  • Alabama
  • Alaska
  • Arizona
  • Colorado
  • Connecticut
  • Florida
  • Georgia
  • Indiana
  • Kentucky
  • Louisiana
  • Massachusetts
  • Mississippi
  • New Mexico
  • North Carolina
  • Ohio
  • Puerto Rico
  • Rhode Island
  • South Carolina
  • Tennessee
  • Texas
  • Utah
  • Washington state

 

 

 

 

 

 

Product Name: BlueCard PPO network

Leidos Group Number: 17010

Anthem Blue Cross Customer Service Phone: 866-403-6183

Submit Claims to your local state Blue Cross or:

Anthem Blue Cross
P.O. Box 60007
Los Angeles, CA 90060

Web site: Anthem

Mail Order: Express Scripts

Mail Order Address:

Express Scripts
P.O. Box 650322
Dallas, TX 75265-0322

Participants may fill prescriptions by sending a prescription and mail order pharmacy form to Express Scripts. For refills, participants can submit requests directly to Express Scripts:

  • Through the Express Scripts web site
  • By phone 877-223-4721; or
  • By returning the mail order pharmacy order form.

 

What is Covered

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 Leidos Medical Plans for more detail.

The Leidos self-insured 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;
  • 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; and
    • Convalescent facility expenses: Charges for a person who is confined to convalesce from a disease or injury for room and board and general expenses made in connection with room occupancy, use of special treatment rooms, X-ray and lab work; physical, occupational or speech therapy; oxygen and other gas therapy; and medical supplies. Benefits will be paid for up to the maximum number of days during any one convalescent period for the same or related cause beginning on the day the person is confined in a convalescent facility if he or she:
      • Was confined in a hospital while covered under the plan for treatment of a disease or injury;
      • Is confined in the facility within 15 days after discharge from the hospital; and
      • Is confined in the facility for services needed to convalesce from the condition that caused the hospital stay.
    Benefits end when the person has not been confined in a hospital, convalescent facility or other place giving nursing care for 90 days in a row.
  • Periodic health assessments (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 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;
  • 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, uterine embryo lavage, embryo transfer, gamete intrafallopian tube transfer (GIFT), zygote intrafallopian tube transfer (ZIFT), low tubal ovum transfer and 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;
    • 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 or equal to 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, if medically necessary, and maintenance therapy (both limited to 52 visits, with pre-certification being required after the 24th visit) for certain chronic medical conditions seriously limiting a member's activities of daily living;
  • Occupational therapy, if medically necessary;
  • Speech therapy for loss of speech, or speech impaired or developmentally delayed due to a diagnosed disease, injury or congenital defect;
  • Sex-change surgery or any treatment of gender identity disorders;
  • Artificial limbs and eyes;
  • Wigs for hair loss due to injury, disease or treatment of disease, including costs for repair or replacement.
  • 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.

 

What is not Covered

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;
  • Hearing aids;
  • 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;
  • Treatment in a convalescent facility for drug addiction, chronic brain syndrome, alcoholism, senility, mental retardation and any other mental disorder;
  • 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;
  • Examinations to determine the need for, or adjustment of, hearing aids;
  • 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;
  • Treatment resulting from an intentionally self-inflicted injury;
  • 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.

 

Comparing the Healthy Focus Medical Plans

The chart below provides some basic plan information about the 2017 Leidos self-insured plans. Download the 2017 Healthy Focus Medical Plan Comparison for a PDF version of the table below.

  Healthy Focus Advantage Plan Healthy Focus Essential Plan
  Network* - Employee Pays Out-of-Network** - Employee Pays Network* - Employee Pays Out-of-Network** - Employee Pays

Annual Deductible1

$1,300 (individual)
$2,600 (family) 2

$1,300 (individual)
$2,600 (family) 2

$2,000 (individual)
$4,000 (family) 2

$2,000 (individual)
$4,000 (family) 2

Annual Out-Of-Pocket Maximum (OOP)
(includes deductible)

$3,000 (individual)
$6,000 (family)
Embedded OOP - N/A

$3,000 (individual)
$6,000 (family)
Embedded OOP - N/A

$5,000 (individual)
$10,000 (family)
Embedded OOP - $7,150 (Individual within Family)

$5,000 (individual)
$10,000 (family)
Embedded OOP - $7,150 (Individual within Family)

Office Visits -
Preventive Care

0% no deductible

50% after deductible

0% no deductible

50% after deductible

Office Visits -
Non-Preventive

20% after deductible

50% after deductible

35% after deductible

50% after deductible

Emergency Room

20% after deductible

50% after deductible

35% after deductible

50% after deductible

Hospital Admission

20% after deductible

50% after deductible

35% after deductible

50% after deductible

Periodic Health Assessments
(Preventive Care)***

0% no deductible; one exam every calendar year

50% after deductible; one exam every calendar year

0% no deductible; one exam every calendar year

50% after deductible; one exam every calendar year

Well-Child Care
(Preventive Care)***

0% no deductible

50% after deductible

0% no deductible

50% after deductible

Lab and X-Ray

20% after deductible for non-routine lab & x-ray services provided outside the office visit

50% after deductible

35% after deductible for non-routine lab & x-ray services provided outside the office visit

50% after deductible

Outpatient Surgery

20% after deductible

50% after deductible

35% after deductible

50% after deductible

Routine Mammograms***

0% no deductible. Age 40 and over: maximum one per calendar year

50% after deductible; Age 40 and over: maximum one per calendar year

0% no deductible. Age 40 and over: maximum one per calendar year

50% after deductible; Age 40 and over: maximum one per calendar year

Routine Pap Smears***

0% no deductible; maximum one per calendar year

50% after deductible; maximum one per calendar year

0% no deductible; maximum one per calendar year

50% after deductible; maximum one per calendar year

PSA/DRE***
(Over age 40)

0% no deductible; over age 40: max 1 visit per year

50% after deductible

0% no deductible; over age 40: max 1 visit per year

50% after deductible

Skilled Nursing Facility

20% after deductible for up to 60 days per confinement

50% after deductible for up to 60 days per confinement

35% after deductible for up to 60 days per confinement

50% after deductible for up to 60 days per confinement

Home Health Care
(maximum visits combined with skilled nursing care and private duty nursing)

20% after deductible for up to 100 visits per year, up to 4 hours = 1 visit

50% after deductible for up to 100 visits per year, up to 4 hours = 1 visit

35% after deductible for up to 100 visits per year, up to 4 hours = 1 visit

50% after deductible for up to 100 visits per year, up to 4 hours = 1 visit

Private Duty Nursing
(maximum visits combined with Home Health Care benefit)

20% after deductible for up to 100 visits per year, up to 8 hours = 1 visit

Not covered

35% after deductible for up to 100 visits per year, up to 4 hours = 1 visit

Not covered

Hospice Care
(up to 30 days per lifetime for inpatient and $10,000 per lifetime for outpatient)

20% after deductible

50% after deductible

35% after deductible

50% after deductible

Outpatient Rehabilitation - Physical and Speech
(as medically necessary)

20% after deductible

50% after deductible

35% after deductible

50% after deductible

Durable Medical Equipment

20% after deductible

50% after deductible

35% after deductible

50% after deductible

Mental Health and Substance Abuse -
Outpatient

20% after deductible

50% after deductible

35% after deductible

50% after deductible

Mental Health and Substance Abuse -
Inpatient

20% after deductible

50% after deductible

35% after deductible

50% after deductible

Most Other Services

20% after deductible

50% after deductible

35% after deductible

50% after deductible

Retail & Mail Order Prescriptions

$5 after deductible (generic)
30% after deductible (brand formulary)
50% after deductible (brand non-formulary)

$5 after deductible (generic)
30% after deductible (brand formulary)
50% after deductible (brand non-formulary)

* Covered services received from a network provider will be paid based on the negotiated rate.

** Covered services received from an out-of-network provider will be paid based on the usual, reasonable and customary (UR&C) limit for the specific service in that geographic region.

*** Medically necessary services/procedures more frequent than the schedule outlined above will be covered and subject to applicable coinsurance.

1 Network and Out-of-Network annual deductibles are not combined.

2 Also, the family deductible is an aggregate deductible where you must satisfy entire deductible before the plan pays benefits for any member.

3 Deductible does not apply for certain preventive drugs.


 

Prescription Drug Coverage

If you are enrolled in one of the Healthy Focus medical plans, you have access to prescription drug coverage through Express Scripts. Below is the plan design for our prescription drug program.

  Healthy Focus Advantage Healthy Focus Essential
  Network Out-of-Network Network Out-of-Network

Generic

$5 after deductible

$5 after deductible

Formulary (Preferred Brand)

30% after deductible

30% after deductible

Non-Formulary (Non-Preferred Brand)

50% after deductible

50% after deductible

For the 2017 plan year, refer to the Preferred Drug List of Exclusions for the annual formulary updates.

For certain preventive drugs, there’s no deductible. Employees just pay the applicable copay or coinsurance. See the 2017 preventive drug list to see if your prescription is included.

Clinical Management Programs

  • Prior Authorization — a feature of your prescription drug benefits that monitors certain prescription drugs and their costs to get you the medication that you require while monitoring your safety and reducing costs.
  • Step Therapy — intended to control the costs and risks posted by certain prescription drugs. Your drug therapy would begin with the most cost-effective and safest drug and progress to other more costly or risky drug therapies.

For more information on your Healthy Focus plan prescription drug coverage, visit the Healthy Focus site.


 

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 Claims Administrator.

Aetna out-of-network claims should be submitted on the Aetna Medical claim form and mailed to:

Aetna Inc.
P.O. Box 14089
Lexington, KY 40512-4089

Anthem out-of-network claims should be submitted on the Anthem Medical Claim form and mailed to:

Anthem Blue Cross
P.O. Box 60007
Los Angeles, CA 90060

If a participant has concerns about how a claim has been administered or wishes to appeal a claims decision, he or she may refer to information on relevant procedures available in the Claims Appeal and Review Procedures Under ERISA in the Plan Information section.