WIXLIB

Johns Hopkins US Family Health Plan. . . . . . . . . . . . . . . . . . . . . . . . . . 3Behavioral Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Long History with the Uniformed Services. . . . . . . . . . . . . . . . . . . . . . 3How to Self-Refer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16How the Plan Works. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3Utilization Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17Getting Started. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4Pharmacy and Prescription Drug Service . . . . . . . . . . . . . . . . . . 18-21Member ID Card Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5Retail Pharmacy Network . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18The Role of Your Primary Care Manager. . . . . . . . . . . . . . . . . . . . . . . . 6Home Delivery/Mail Order Pharmacy. . . . . . . . . . . . . . . . . . . . . . . . 18If You Need Specialty Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Vaccine Administration at Walgreens Pharmacies. . . . . . . . . . . . . . . 18If You Are Admitted to a Hospital . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Formulary and Co-Payments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Choosing Your Primary Care Manager . . . . . . . . . . . . . . . . . . . . . . . . 6Covered Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Hospital Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Non-Covered Medications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Accessibility of Services. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6Formulary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19Emergency Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Generic Drug Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19After-Hours Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Quantity Limits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20NurseLine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Prior Authorization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Nurse Chat Line. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Step Therapy. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20Virtual OnDemand. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Medical Necessity for Non-Formulary Medications . . . . . . . . . . . . 20Medline Plus. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7Out of Network Claims/Reimbursement. . . . . . . . . . . . . . . . . . . . . . 21Non-Emergency Urgent Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Online Coordination of Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21In The Plan Area. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Specialty Medications. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Outside The Plan Area . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Drug Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Emergency or Urgent Care Out of the Country or at Sea . . . . . . . . 8Prescription Drug Recalls. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21Emergency Prescriptions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Skilled Nursing Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8-9Inpatient Skilled Nursing Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Covered Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8Home Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Point of Service (POS) Option . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9Enrollment in the Plan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22-26Catastrophic Loss Protection Benefit (Catastrophic Cap) . . . . . . . 9Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22Plan Benefits Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10-11Beneficiary Web Enrollment (BWE) . . . . . . . . . . . . . . . . . . . . . . . . . . 22Footnotes to Plan Benefits Chart. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Military Treatment Facility Privileges . . . . . . . . . . . . . . . . . . . . . . . . . 23Limitations to Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Changes Affecting Eligibility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23Examples of Specific Exclusions and Limitations . . . . . . . . . . . . . . . 11Enrollment Fees . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24Other Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12-15Moving with TRICARE Prime . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Ambulance Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Split Enrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Dental Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Disenrollment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25Vision Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12Other Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Diagnostic Services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Coordination of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26Hospice Care. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Third-Party Liability and Work-Related Injury . . . . . . . . . . . . . . . . 26Behavioral Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13Insurance Changes. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26National Cancer Institute Clinical Trials. . . . . . . . . . . . . . . . . . . . . . 14Marketing and Enrollment Limitations . . . . . . . . . . . . . . . . . . . . . . . 26Durable Medical Equipment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14Customer Service . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26ECHO (Extended Care Health Option) . . . . . . . . . . . . . . . . . . . . . . 14Claims and Member Reimbursements . . . . . . . . . . . . . . . . . . . . . 27-28Evaluation of New Technology, Drugs, and Benefits . . . . . . . . . . . 15Grievances, Complaints and Appeals. . . . . . . . . . . . . . . . . . . . . . . . . . 27Care Management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15-18Members’ Rights and Responsibilities . . . . . . . . . . . . . . . . . . . . . 28-29Preventive Health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Privacy and Confidentiality . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Transition of Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Fraud and Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29Complex Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16Definition of Terms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30-31J O H N S H O P K I N S U S FA M I LY H E A LT H P L A N M E M B E R H A N D B O O KTable of Contents1

2022MemberHandbookJ O H N S H O P K I N S U S FA M I LY H E A LT H P L A NWelcometo the Johns Hopkins US Family Health Plan (the Plan) for retirees and theirfamily members (under 65 years of age) and active-duty family members of the sevenuniformed services . This Member Handbook provides you with the information youwill need to get the most from the Plan and to ensure that you know the best way toobtain the services and benefits .New to the Johns HopkinsUS Family Health Plan?Read Your HandbookCarefullyYou may have questions and concerns regardingvarious aspects of your coverage and how thePlan works . Our highly trained customer servicerepresentatives are ready to answer your questions,help you locate a primary care provider or aspecialist, or provide other assistance you mightneed . We are available Monday through Friday8:00 a .m . to 4:30 p .m .The Member Handbook is a summary of eligibilityrequirements, medical coverage, co-payments,definition of terms, exclusions, and other provisionsof the US Family Health Plan .Telephone:410-424-4528 or toll free, 1-800-808-7347E-mail:usfhpcustomerservice@jhhc .com2Please note: This handbook is only as current as thedate of publication and is subject to change withoutnotice . The Member Handbook is also availableon our website and should be used as an additionalresource . The handbook is located on the home pageat the following address:hopkinsusfhp .orgUpdates are also provided to members by individualmailings or in The Patriot Life, the quarterlymember newsletter .

The Johns Hopkins US Family Health Plan(USFHP) or (the Plan) is a Department ofDefense (DoD) sponsored program that deliversTRICARE Prime benefits to retirees and theirfamily members, active-duty family members andsurvivors of the seven uniformed services, includingthe Army, Navy, Marine Corps, Air Force, CoastGuard, Public Health Service, and the NationalOceanic and Atmospheric Administration(NOAA) .Johns Hopkins Community Physicians (JHCP)serves as the largest primary care provider group inMaryland . Composed of more than 400 physiciansand other health professionals practicing in manyneighborhood locations throughout Marylandand the District of Columbia, JHCP offers the fullrange of primary care services and some specialtyservices . Some locations also offer additionalon-site services, including pharmacy, labs, X-ray,ophthalmology and optometry . USFHP alsopartners with community primary care providersthroughout parts of West Virginia, and Maryland,Northen Virginia, Delaware, D .C . and SouthCentral Pennsylvania . Specialty care is available byreferral to Johns Hopkins specialist physicians orthe Plan’s extensive network of local communityparticipating providers .Long History with theUniformed ServicesJohns Hopkins’ history of providing health care tothe military began when seven U .S . Public HealthService Hospitals were transferred to private healthcare entities with the stipulation that they continueto care for the uniformed services beneficiariesthrough their federal designation as UniformedServices Treatment Facilities . Following theclosure of the Baltimore U .S . Public Health ServiceHospital, the Wyman Park Health System wasestablished (1982) and was subsequently acquiredby the Johns Hopkins Health System (1986) .In 1993 the DoD reorganized these facilities intothe Uniformed Services Family Health Plan . It wasthe first DoD-sponsored, full-risk, managed healthcare plan .The USFHP has been serving military families formore than 30 years and is a part of the militaryhealth system known as TRICARE .How the Plan WorksJohns Hopkins US Family Health Plan isa managed care plan, designed to providecomprehensive TRICARE Prime medical benefitsto enrolled individuals at a low out-of-pocketcost . A managed care plan is an organized systemof health care delivery that relies on a primarycare manager (PCM)—a pediatrician, familypractitioner or internist—to arrange for all ofyour health care needs with specific providers andhospitals . Payment for these services is handledby the Plan . Full coverage for covered benefits isavailable only from Plan providers except during amedical emergency . There are no claim forms whenPlan-approved providers are used .Because the Plan provides or arranges for your careand pays the cost of all authorized services (less anyapplicable co-payments/cost-shares), every effortwill be made to provide efficient and effectivedelivery of health care services .J O H N S H O P K I N S U S FA M I LY H E A LT H P L A N M E M B E R H A N D B O O KThe Johns HopkinsUS Family Health Plan3

Getting StartedHow To Select Your ProvidersMember HandbookMembers have access to a fully accredited networkmade up of more than 16,500 primary care andspecialty physicians as well as 50 hospitals, ensuringthat you can find care and services near you .To ensure you get off to a good start, please read theinformation included in the new member packetcarefully and save this Member Handbook for futurereference, as it has important information about thebest way to use the benefits and services provided byJohns Hopkins US Family Health Plan .Website / Healthlink Secure WebPortalTo locate a doctor (primary care or specialty care),visit hopkinsusfhp .org and click on Find a Doctor .This feature allows you to search for a doctor bycity, state, field of practice and much more . Ifyou want more information regarding a healthcare practitioner’s background, qualifications andexperience, call Customer Service at 410-424-4528or toll-free at 1-800-808-7347 .After you review this handbook and the otherinformation in the packet, please visithopkinsusfhp .org for the latest updates on Planbenefits and services, news, and the latest copy ofthe Plan newsletter . You can also create an accounton our secure online portal HealthLINK@Hopkins . Among other features, this portal allowsyou to:Note: If you are currently receiving medical servicesoutside the Johns Hopkins US Family Health Plannetwork, you will need to change to Plan-approvedproviders . Your new primary care office will assist youin transferring your records to the Plan . Rememberthat in order to be fully covered, all outside servicesmust be authorized by your primary care manager(PCM) . Search for providers by location, languagespoken, gender and professional qualifications Change your primary care doctor, also calledyour primary care manager (PCM) Review and maintain your personal healthrecord (PHR) Review your eligibility and benefit coverage Access pharmacy benefit information Send secure messagesCustomer ServiceWe also have a specially trained staff of customerservice representatives available to you between8:00 a .m . and 4:30 p .m . Monday through Friday .You may reach a representative by calling410-424-4528 or toll-free at 1-800-808-7347 .Interpreter ServicesMany of our physicians and hospitals have on-siteinterpreting services . To request an interpreter,please call Customer Service at 1-800-808-7347 .Assistance for the hearing impaired can be accessedthrough Maryland Relay by dialing 7-1-1 or1-800-201-7165 .4Primary Care LocationsThe Johns Hopkins US Family Health Plan hasmany primary care locations throughout Maryland,Northern Virginia, Delaware, D .C . and SouthCentral Pennsylvania . We are always addingproviders to our network . To find a locationnearest you, visit hopkinsusfhp .org and click onFind a Doctor or call Customer Service at410-424-4528 or 1-800-808-7347 .

Your Johns Hopkins US Family Health Plan member ID card will be mailed to you from the card vendor,separately from your welcome kit . This card provides important information about your Plan membership,relating to coverage for primary care, specialty care, pharmacy benefits and other covered benefits .Additionally, your card provides information about co-payments and important telephone numbers, andwill authorize you to receive services under the Plan . (See below for details .)PRODUCTION VIEWPlease carry your card with you at all times and show it at each office visit .If your membership card gets lost or damaged, please contact Customer Service at 410-424-4528 or1-800-808-7347, Monday throughFriday from 8 a .m . to 4:30 p .m .12/01/2021Processed DateMember Name SAMPLE CARD USFHPMember IdJob IdExpected Mail DateActual Mail Date689101949913357SAMPLE ID CARDCard FrontCard Back(Your actual card may appear slightly different)Your unique membershipidentification numberPRODUCTIONEffectiveVIEWdateCard Front#: 689101949: 01/01/2022CoPays:Spec: 0 ER: 0www.hopkinsusfhp.orgPCN: ADVGrp: RX4291BIN: 004336Card Backwww.hopkinsusfhp.orgUS Family Health PlanMEMBER INFORMATIONX103970100001A TRICARE Primedesignated provider.AMPLE CARD USFHPCP AT ODENTON FP IM MEDone #: 410-874-140012/01/2021EMERGENCY CARE:If you are experiencing a life-threatening emergency, call 911 or proceed to the nearest emergency room.You must notify your primary care manager within 24 hours of an emergency room visit and any follow up caremust be pre-approved. If you are unsure if your condition is life-threatening, call your Primary Care Manager first.AFTER-HOURS CARE:Contact your primary care provider's after hours service. For nurse advice and answers to your health.questions 24 hours a day, contact our Nurseline: 1-844-344-4218BEHAVIORAL HEALTH SERVICES: 1-888-281-3186BENEFITS: For information, call Customer Service at 410-424-4528 or 1-800-808-7347HOSPITAL PROVIDER INFORMATIONCall the plan five days prior to an elective admission or outpatient procedure to obtain authorization.If the patient holds other commercial health insurance, bill that carrier as primary.DO NOT BILL MEDICARE except for ESRD and services not covered by the US Family Heath Plan.For Claims Submission only: P.O. Box 830479Birmingham, AL 35283-0479The information on the back of your membership card helpsyou obtain care you may require unexpectedly . It also giveshealth care providers information on how to process yourclaims . Please remember to carry this membership card withyou at all times .X103970100001CARD USFHP IdentifyingProcessednumbers Date9Expectedto assist in processingMail DateActual Mail Dateyour prescriptionsMail To ASAMPLE7231 PAHANOVESingle CUS Family Health PlanMEMBER INFORMATIONA TRICARE Primedesignated provider.Name:MailSAMPLECARD USFHPTo AddressPCM: SAMPLEJHCP AT ODENTONFP IM MEDCARD USFHPPCM Phone #: 410-874-14007231 PARKWAY DRMember #: 689101949HANOVERMD 21076-1788Effective:01/01/2022CoPays:PCP: Single 0 Spec: 0 PackageER: 0CardJ O H N S H O P K I N S U S FA M I LY H E A LT H P L A N M E M B E R H A N D B O O KMember ID Card OverviewEMERGENCYCARE:Your medicalpracticeare experiencing a life-threatening emergency, call 911 oor PCMIfYouyoumustnotify your primary care manager within 24 hours of amust be pre-approved. If you are unsure if your condition is lifeAFTER-HOURS CARE:Contact your primary care provider's after hours service. Fquestions 24 hours a day, contact our Nurseline: 1-844-34BEHAVIORAL HEALTH SERVICES: 1-888-281-31BENEFITS: For information, call Customer Service at 4HOSPITAL PROVIDER INFORMATIONCall the planfive days prior to an elective admission or outCo-paymentsapplicableIf the patient holds other commercial health insurance, billDONOTBILLMEDICAREexcept for ESRD and servicesto your membershipplanFor Claims Submission only: P.O. Box 830479Birmingham, AL 35283-0475

The Role of YourPrimary CareManagerAs a member of the Plan, you will establish arelationship with a USFHP primary care manager(PCM) who will get to know you, your medicalhistory and your individual health care needs . Ourprimary care managers are trained in family practice,internal medicine or pediatrics .Your PCM sees you for all of your routine healthneeds, monitors the medications you receive,orders tests or special services like physical therapyand maintains your medical records . If you have acomplex health condition, your PCM may refer youto one of Johns Hopkins US Family Health Plan’smany qualified specialists . Your PCM and the Planspecialist will work together as a team to meet yourhealth care needs .If You Need Specialty CareTo see a specialist or other type of provider, youmust obtain a referral from your PCM . The onlyexceptions are: Life-threatening medical emergencies Routine annual vision screening examsYour PCM will choose an appropriate specialist foryour care . If, at the time you enroll, you are under thecare of a medical specialist who practices outside theJohns Hopkins network, your PCM may transferyour specialty care to a Plan provider . Every effortwill be made to ensure that there is continuity inyour care . Each time you choose to see a non-Planprovider for a covered service in a non-emergencysituation, the service(s) will be paid under the pointof service (POS) provision . Please see page 9 for a fullexplanation of the POS benefit .If You Are Admitted to a HospitalIf you require hospitalization, your PCM orspecialist will make the necessary arrangements foryou . Inpatient care will be provided at any of ourparticipating hospitals . Your hospital care will becoordinated by your PCM or another Plan provider .Emergency care will be covered at any hospital .Note: If you are admitted to a hospital as anemergency, your PCM must be notified as soon aspossible or the next business day .6Choosing Your Primary CareManagerThe first and most important decision you will makeis the selection of a primary care manager . Eachenrollee in your family should select a PCM withwhom he or she is comfortable . Family membersdo not need to select the same PCM, and theirselections may be changed upon request .You can locate primary care managers (PCMs)by visiting: hopkinsusfhp .org and click on Finda Doctor . This feature allows you to search for adoctor by city, state, field of practice and much more .Be sure to search for a PCM by choosing, familypractitioners, pediatricians, internists and nursepractitioners .If you don’t have access to a computer, call CustomerService at 410-424-4528 or toll-free at1-800-808-7347 for assistance .Hospital ServicesThe Plan provides a comprehensive range ofhospital benefits with no dollar or day limit whenhospitalization occurs under the care of a Planprovider

referral to Johns Hopkins specialist physicians or the Plan's extensive network of local community participating providers . Long History with the Uniformed Services Johns Hopkins' history of providing health care to the military began when seven U .S . Public Health Service Hospitals were transferred to private health