Open Enrollment Judiciary of Guam - SelectCare
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Judiciary of Guam Open Enrollment Fiscal Year 2021
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Buenas yan Hafa Adai!
We would like to welcome the Judiciary of Guam employees and dependents to our health plan. We
look forward to servicing you for FY2021. The landscape of healthcare continues to evolve and we will
continue to improve the benefits, services and medical networks available to you.
You are able to choose from two (2) plans: the PPO750 and the HSA2000.
Below are some key features of the plans that will be available to you:
• A comprehensive and extensive medical network
• Wellness Rewards program
• 100% coverage for Preventive Services without meeting the deductible in accordance with
the United States Preventive Services Task Force (USPSTF), Grade A and B recommendations
• 100% Prenatal care coverage without having to meet the deductible
• Membership in the Calvo’s LifeStyle Club that provides you numerous savings and discounts at
popular merchants on Guam
• 50% Air Ambulance discount (pre-approval and limitations apply)
• $500 Travel Benefit to Participating Providers in the Philippines or in Taiwan
(pre-approval and limitations apply)
• Airfare to our Centers of Excellence for certain qualifying and pre-approved conditions
We are pleased to announce that we have expanded our off-island
provider network through a partnership with UnitedHealthcare.
You now have access to services all across the continental United States:
1.1 million providers | 560 Centers of Excellence | 6,100 hospitals
New business practices have been established such as video conferencing and webinars to better
serve you while abiding to the current pandemic protocols. We also improved our web portal for easier
interaction. Visit our website at calvos.net, to obtain claim payments, explanation of benefits, schedule
of benefits, and other pertinent information.
We encourage you to participate in our customer surveys as they are an important tool in evaluating
and improving our services. We thank you in advance for your support and for the trust that you and
your family have placed with us.
Si Yu’os Ma’ase!
Thank you for enrolling with Calvo’s SelectCare!
Becoming a Member
Eligibility Information • Q.M.C.S.O. or a copy of the qualified medical child support order must
In order to enroll in a Calvo’s SelectCare health plan, you and your be provided. Children permanently residing outside the service area
dependents must first meet the eligibility requirements defined in the are only eligible to enroll in the plan if they qualify under the Q.M.C.S.O.
agreement between Calvo’s SelectCare and The Judiciary of Guam.
Enrollment Period
You must complete an Enrollment Application and submit it with any other
You may elect to enroll on any of these occasions.
required documentation during an Open Enrollment period or within 30
days from the date you first become eligible for enrollment under the plan. • Initial Employment. You may enroll within 30 days from the date you
first become eligible to enroll in the plan.
Subscriber Eligibility Requirements
• Annual Open Enrollment Period.
• You must maintain legal residency in the Service Area. Calvo’s
SelectCare members must not be absent from the Service Area for • Special Enrollment Periods: Full-time employees and their eligible
more than 90 consecutive days. dependent(s) may enroll outside of open enrollment as a result of a
Qualifying Event as defined by H.I.P.A.A. Under H.I.P.A.A. a Qualifying
Dependent Eligibility Requirements Event is an event that causes you to lose coverage in another health
Aside from meeting the eligibility requirements set forth by your employer, plan due to:
family members are eligible for coverage as dependents provided they are:
• Termination of spouse’s coverage or death of your spouse.
• Your legal spouse.
• Divorce, Annulment or Legal Separation from your spouse.
• Your domestic partner:
• Medicare or Medicaid eligibility ends.
• A domestic partner must be at least 18 years of age and must have
A Special Enrollment opportunity also occurs if you acquire a new
lived with you for two consecutive years. A notarized affidavit is
dependent through:
required.
• Birth or Adoption.
• A domestic partner may only be added during your employer’s • Legal Guardianship.
Open Enrollment Period or within 30 days from the date you first • Marriage.
become eligible to enroll in the plan.
Enrollment Applications or Change of Status (COS) Forms and any required
• Children of a domestic partner are eligible for coverage so long as documents must be submitted within 30 days following a Qualifying
the domestic partner is a covered person. Event. If you have lost coverage in another health plan due to a Qualifying
Event, you are also required to submit a H.I.P.A.A. Certificate of Creditable
• Married or unmarried dependent children under the age of 26 years.
Coverage from your previous plan. Your previous plan is required to issue
• Off-island Dependent children or children who reside outside the a H.I.P.A.A. Certificate to you in a timely manner.
Service area who are between the ages of 19 thru 25 years.
Your coverage will begin on the first day of the first Premium Period
• Coverage for off-island dependent children will terminate upon following receipt of your Enrollment Application by Calvo’s SelectCare.
reaching the age of 26 years.
For more information, please refer to the “Summary of Federally Mandated
• For natural children with a different last name from your own, you must Programs” section of your Member this Handbook.
provide the following:
Adding Dependents and Changes to your Coverage
• A copy of the birth certificate which verifies you as a parent, or
You are able to enroll your new dependent(s), if you get married, obtain
• A notarized government Paternity Form which verifies you as a legal guardianship, adopt a child or have a newborn baby as long as they
natural parent. meet the eligibility requirements. Coverage begins on the first day of a
Premium Period, however, coverage for newborn dependents begins at
• For other dependents such as step children, legally adopted children,
birth, and coverage for adopted dependents begins on the actual date of
and children you have been awarded legal guardianship, you must
custody of the dependent.
provide the following:
If you do not enroll your dependents within the 30 day period from when
• Birth Certificate.
they first become eligible, you would have to wait to enroll them during
• Parents’ marriage certificate (when required). the next Open Enrollment Period.
• Legal Guardianship must be for “Full Guardianship” and not limited To add dependents, you, as the subscriber must notify Calvo’s SelectCare
or shared. A copy of the guardian’s latest income tax filing or an in the following manner:
affidavit stating that the dependent will be included in the guardian’s
• Complete a “Change of Status” Form (COS),
next tax filing.
• Complete a “Health Statement” Form (when required by the plan),
• Court documentation signed by a judge ordering adoption or legal
guardianship. • Submit all Required Documentation as outlined above,
• Legal guardianship terminates no later than age 26. • Make your request within 30 days of your dependent first becoming
eligible.
• Unborn children awarded for legal guardianship are not eligible for
coverage.
Updating Your Information
• Your disabled dependent child who is beyond the limiting age may Your Enrollment Application contains pertinent information. This
continue to be eligible provided they are incapable of self-sustaining information is very important because it identifies you and your
employment due to mental retardation or physical disability. dependent(s) as eligible members. Please inform our Customer Service
Department immediately of any error on your Member ID Card or any
• Proof of total disability from a licensed medical physician is required
changes in name, address, phone numbers or email address.
upon enrollment.
• Proof of dependence, such as a copy of the subscriber’s tax filing
may be required.
1 This handbook is designed to provide information about your Calvo’s SelectCare plan.
In the event of a discrepancy between this Handbook and the contract, the terms of the contract will prevail.
Judiciary of Guam
Schedule of Benefits
Your Benefits: What the plan covers Participating Providers Non-participating Providers
Deductible Per Individual Member (Class 1) $2,000 **$4,000
Deductible Per Family (Classes 2-4) $4,000 **$12,000
If a member meets their $2,600 deductible, the plan begins to pay for covered services for that individual
Coverage Maximums None None
Individual member annual maximum
Out of Pocket Maximums (includes deductible and co-payments)
Per Individual member per policy year $4,000 No Maximum
Per Family per policy year $11,900 No Maximum
Medical and Prescription Out of Pocket Maximums are combined
Off-Island Services Prior Authorization from your doctor and approval from the Plan is required
Any services in the Philippines, Asia, Hawaii, U.S. Mainland and any other foreign participating providers prior to services rendered at off-island facilities. Covered benefits at
Participating Philippine Providers are payable 100% after deductible is met
Deductible does not apply to these benefits Participating Providers Non-participating Providers
when you go to a Participating Provider Deductible does not apply after Deductible is met
Preventive Services (Out-Patient Only)
Includes Annual Preventive Exams and Preventive Lab Services (Guam and Philippines only) Plan pays 100% *Plan pays 70%, Member pays 30%
In accordance with the guidelines established by the U.S. Preventive Services Task Force (USPSTF) Grades A and B recommendations
Outpatient Laboratory (Preventive & Diagnostic) Plan pays 100% *Plan pays 70%, Member pays 30%
Immunizations/Vaccinations
Plan pays 100% *Plan pays 70%, Member pays 30%
In accordance with the guidelines established by the CDC Advisory Committee on Immunization Practices
Pre-Natal Care
Plan pays 100% *Plan pays 70%, Member pays 30%
Including Routine Labs and First Ultrasound
Well-Child Care
In accordance with Bright Futures/American Academy of Pediatrics recommendations for Preventive Pediatric Health Care
1. Infancy (Newborn to 9 months) - Maximum 7 visits Plan pays 100% *Plan pays 70%, Member pays 30%
2. Early Childhood (1 to 4 years old) - Maximum 7 visits
3. Middle Childhood/Adolescence (5 to 17 years old) - Maximum 1 visit per year
Well-Woman Care
In accordance with the guidelines supported by the Health Resources and Services Administration (HRSA) and the Women’s Health
and Cancer Act Plan pays 100% *Plan pays 70%, Member pays 30%
• Contraceptives including Sterilization and Tubal Ligation if prescribed
• Includes coverage for Breast Pumps
Annual Eye Exam
$20 Member Co-payment *Plan pays 70%, Member pays 30%
Once per member per plan year
Participating Providers Non-participating Providers
Deductible must be met for the following services after Deductible is met after Deductible is met
Outpatient Physician Care & Services
1. Primary Care Visits $20 Member Co-Payment
2. Specialist Care Visits $40 Member Co-Payment
3. Voluntary Second Surgical Opinion $40 Member Co-Payment
4. Urgent Care Visits $50 Member Co-Payment
5. Mental Health Care and Substance Abuse Visits $20 Member Co-Payment *Plan pays 70%, Member pays 30%
6. Home Health Care Visit (Prior Authorization Required) Plan pays 100%
7. Hospice Care in Guam only, maximum of $100 per day (Prior Authorization Required) Plan pays 100%
8. Routine Diagnostic Tests (X-ray, ultrasound, ECG, EEG, EMG & non-routine mammogram) $20 Member Co-Payment
9. Injections (Does not include those on the Specialty Drugs List) $20 Member Co-Payment
Emergency Care
(For an on and off-island emergencies, plan must be contacted and advised within 48 hours) $75 Member Co-payment plus any
$75 Member Co-Payment
The co-payment will be waived if you are admitted to the hospital from the emergency room difference in Eligible charges and
1. On/Off-Island emergency facility, physician services, laboratory, X-Rays billed charges
Ambulance Services (Ground transportation only) Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Acupuncture Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Airfare Benefit to Centers of Excellence only
Plan pays 100% Not Covered
For members who meet qualifying conditions, Plan provides round trip airfare (Plan Approval Required)
* Plan pays 70% of eligible charges, Member pays 30% coinsurance of eligible charges plus any difference between eligible charges and billed charges. Eligible Charges for A full list of the Medical Exclusions can
Non-Participating Providers are limited to the lesser of actual charges or Medicare’s participating provider fee schedule in the geographic location where the service was be found in the Judiciary of Guam
rendered unless otherwise provided in the Agreement. The Covered Person pays any excess above Eligible Charges.
FY2021 Member Handbook.
**A separate deductible applies for services rendered by Non-Participating Providers
This handbook is designed to provide information about your Calvo’s SelectCare plan. 2
In the event of a discrepancy between this Handbook and the contract, the terms of the contract will prevail.
Participating Providers Non-participating Providers
Deductible must be met for the following services after Deductible is met after Deductible is met
Allergy Testing
Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
$500 per member per plan year
Ambulatory Surgi-center Care (Prior Authorization Required) Includes medically necessary anesthesia Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Autism Spectrum Disorder Coverage
Referral from Primary Care Physician and Prior Authorization from Plan is required
Coverage is limited to the following maximums per member per benefit year: $50 Member Co-Payment Not Covered
• $25,000 per benefit year for ages 16-21 years old
• $75,000 per benefit year for ages 0-15 years old
Services are subject to Plans benefit coverage guidelines and medical necessity
Blood & Blood Derivatives Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Breast Reconstructive Surgery (In accordance with 1998 W.H.C.R.A) Includes medically necessary anesthesia Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Cardiac Surgery Includes medically necessary anesthesia Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Cardiac Rehabilitation (Inpatient) Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Up to 30 days following bypass surgery or myocardial infarction
Cataract Surgery Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Includes lens implants. Outpatient Only. Includes medically necessary anesthesia
Chemotherapy Benefit Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Chiropractic Care Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Clinical Trials
Includes phases I-IV outpatient or inpatient clinic trials that are conducted in relation to treatment of cancer or other $40 Member Co-Payment *Plan pays 70%, Member pays 30%
life-threatening diseases or conditions as approved by the National Institute of Health or the National Cancer Institute
Complex Diagnostic Testing Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
MRI, CT scan, and other diagnostic procedures (Prior Authorization Required)
Durable Medical Equipment (DME)
The lesser amount between the Purchase or Rental of crutches, walkers, wheelchairs, hospital beds, suction machines, Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
CPAP machines, BPAP machines, insulin pumps, blood glucose monitors, oxygen and accessories when prescribed by a Physician of the total rental cost or purchase
(Prior Authorization Required)
Elective Surgery (Prior Authorization Required) Includes medically necessary anesthesia Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
End Stage Renal Disease / Hemodialysis Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
At Primary Care
Foot Care (subject to benefit limitations) $20 Member Co-Payment
*Plan pays 70%, Member pays 30%
Foot Care and Podiatry services At Specialist Care
$40 Member Co-Payment
Growth Hormone Therapy Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Hearing Aids
Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Maximum $1,000 per member per 24 months. Limited to 1 device every 3 years
Hearing Services Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Hospitalization & Inpatient Benefits
1. Room & Board for a semi-private room, intensive care, coronary care and surgery
2. All other inpatient hospital services including laboratory, x-ray, operating room, anesthesia and medication Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
3. Physician’s hospital services
4. Mental Health and Substance Abuse Admission
Hyperbaric Oxygen Therapy & Wound Care Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Medically necessary (Prior Authorization Required)
Implants, Orthotics & Prosthetic Devices
Cardiac pacemakers, Intraocular lenses, artificial eyes, heart valves, orthopedic internal prosthetic devices, stents, stump hose, Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
cochlear implants, corrective orthopedic appliances and braces (Limitations apply, please refer to contract)
Inhalation Therapy Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Infertility Services Diagnosis of Infertility Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Maternity Care Labor and Delivery Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Nuclear Medicine (Prior Authorization Required) Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Occupational Therapy (Prior Authorization Required) Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
* Plan pays 70% of eligible charges, Member pays 30% coinsurance of eligible charges plus any difference between eligible charges and billed charges. Eligible Charges for A full list of the Medical Exclusions can
Non-Participating Providers are limited to the lesser of actual charges or Medicare’s participating provider fee schedule in the geographic location where the service was be found in the Judiciary of Guam
rendered unless otherwise provided in the Agreement. The Covered Person pays any excess above Eligible Charges.
FY2021 Member Handbook.
**A separate deductible applies for services rendered by Non-Participating Providers
3 This handbook is designed to provide information about your Calvo’s SelectCare plan.
In the event of a discrepancy between this Handbook and the contract, the terms of the contract will prevail.
Participating Providers Non-participating Providers
Deductible must be met for the following services after Deductible is met after Deductible is met
Oral and Maxillofacial Surgery
Oral surgical procedures, limited to:
• Reduction of fractures of the jaws or facial bones
• Surgical correction of cleft lip, cleft palate or severe functional malocclusion
Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
• Removal of stones from salivary ducts
• Excision of leukoplakia or malignancies
• Excision of cysts and incision of abscesses when done as independent procedures
• Other surgical procedures that do not involve teeth or their supporting structures
Physical Therapy Plan pays 80% for the first 20 visits *Plan pays 70%, Member pays 30%
(Prior Authorization Required) and 50% thereafter
Prescription Drugs
Retail Pharmacy (30-day supply)
1. Formulary generic drugs per prescription unit Member pays 10%
2. Formulary brand name drugs per prescription unit Member pays 20%
3. Non-Formulary (Medically Necessary Only and Prior Authorization Required) Member pays 30% Member pays 30% of Average
4. Specialty Drugs (Medically Necessary Only and Prior Authorization Required) Member pays 30% Wholesale Price (AWP) plus
any difference between
Mail Order Pharmacy (90-day supply) eligible and billed charges
1. Formulary generic drugs per prescription unit $0 Member Co-Payment
2. Formulary brand name drugs per prescription unit $0 Member Co-Payment
3. Non-Formulary (Medically Necessary Only and Prior Authorization Required) Member pays 30%
4. Specialty Drugs (Medically Necessary Only and Prior Authorization Required) Member pays 30%
Radiation Therapy (Prior Authorization Required) Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Reconstructive Surgery
• Surgery to correct a functional defect *Plan pays 70%, Member pays 30%
Plan pays 80%, Member pays 20%
• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm.
Examples of congenital anomalies are protruding ear deformities; cleft lip; cleft palate; birth marks; and webbed fingers and toes
Skilled Nursing Facility
Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Maximum 60 days per member per plan year (Prior Authorization Required)
Speech Therapy (Prior Authorization Required) Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Sterilization Procedures (Prior Authorization Required)
1. Vasectomy (Outpatient Only) Plan pays 100% *Plan pays 70%, Member pays 30%
2. Tubal Ligation (Traditional and with Fulguration)
Diagnostic Sleep Study (Prior Authorization Required) Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Travel Benefit
• Prior authorization (written approval) and coordination is required from Plan prior to departure from Guam
• Applicable only to approved referrals for conditions not treatable on Guam
Member pays all costs above $500
• Airfare and/or lodging expenses coverage for eligible members for approved specialty care visits, consultations, treatments Not Covered
Limited to once per plan year
and hospitalization services at Participating Providers in The Philippines or in Taiwan
• Executive check-ups, preventive services, primary care services and dental care do not qualify for this benefit
• Conditions and limitations apply as specified in the Member Handbook
Additional Benefits: What the plan covers (Deductible does not apply) Participating Providers Non-participating Providers
WELLNESS BENEFITS
1. Wellness Programs at Guam SDA Wellness Center
Free Programs
• Nutrition Consultation Plan pays 100%
• Diabetes Self-Management Training Program
• Stop Smoking Program
• Childbirth Preparation Class
Discounted Programs Not Covered
• 7-day Shape Up Program
• 7-day Detox Program Discounts vary by program
• 7-day Advanced Detox Program
• NEWSTART Program
2. Health and Wellness Rewards
Plan Pays 100% at
• Up to $100 per plan year
Participating Providers
• Please refer to member brochure for Health and Wellness Rewards available
Plan pays 100% up to $200 per
Vision Benefit member per 24 months through
Plan pays 100% up to $200
Coverage for a pair of contact lenses or eyeglasses lens/frames – maximum of $200 per member per 24 months reimbursement, which needs to
per member per 24 months
be submitted to Plan within
90 days from date of service
* Plan pays 70% of eligible charges, Member pays 30% coinsurance of eligible charges plus any difference between eligible charges and billed charges. Eligible Charges for A full list of the Medical Exclusions can
Non-Participating Providers are limited to the lesser of actual charges or Medicare’s participating provider fee schedule in the geographic location where the service was be found in the Judiciary of Guam
rendered unless otherwise provided in the Agreement. The Covered Person pays any excess above Eligible Charges.
FY2021 Member Handbook.
**A separate deductible applies for services rendered by Non-Participating Providers
This handbook is designed to provide information about your Calvo’s SelectCare plan. 4
In the event of a discrepancy between this Handbook and the contract, the terms of the contract will prevail.Schedule of Benefits
Your Benefits: What the plan covers Participating Providers Non-participating Providers
Deductible Per Individual Member (Class 1) $750 **$1,500
Deductible Per Family (Classes 2-4) $1,500 **$4,500
If a member meets their $750 deductible, the plan begins to pay for covered services for that individual
Coverage Maximums None None
Individual member annual maximum
Medical Out of Pocket Maximums (includes deductible and co-payments)
Per Individual member per policy year $2,000 No Maximum
Per Family per policy year $6,000 No Maximum
Prescription Out of Pocket Maximums (includes co-payments)
Per Individual member per policy year $1,500 No Maximum
Per Family per policy year $3,000 No Maximum
Off-Island Services Prior Authorization from your doctor and approval from the Plan is required
Any services in the Philippines, Asia, Hawaii, U.S. Mainland and any other foreign participating providers prior to services rendered at off-island facilities. Covered benefits at
Participating Philippine Providers are payable 100% after deductible is met
Deductible does not apply to these benefits Participating Providers Non-participating Providers
when you go to a Participating Provider Deductible does not apply after Deductible is met
Preventive Services (Out-Patient Only)
Includes Annual Preventive Exams and Preventive Lab Services (Guam and Philippines only) Plan pays 100% *Plan pays 70%, Member pays 30%
In accordance with the guidelines established by the U.S. Preventive Services Task Force (USPSTF) Grades A and B recommendations
Outpatient Laboratory (Preventive & Diagnostic) Plan pays 100% *Plan pays 70%, Member pays 30%
Immunizations/Vaccinations
Plan pays 100% *Plan pays 70%, Member pays 30%
In accordance with the guidelines established by the CDC Advisory Committee on Immunization Practices
Pre-Natal Care
Plan pays 100% *Plan pays 70%, Member pays 30%
Including Routine Labs and First Ultrasound
Well-Child Care
In accordance with Bright Futures/American Academy of Pediatrics recommendations for Preventive Pediatric Health Care
1. Infancy (Newborn to 9 months) - Maximum 7 visits Plan pays 100% *Plan pays 70%, Member pays 30%
2. Early Childhood (1 to 4 years old) - Maximum 7 visits
3. Middle Childhood/ Adolescence (5 to 17 years old) - Maximum 1 visit per year
Well-Woman Care
In accordance with the guidelines supported by the Health Resources and Services Administration (HRSA) and the Women’s Health
and Cancer Act Plan pays 100% *Plan pays 70%, Member pays 30%
• Contraceptives including Sterilization and Tubal Ligation if prescribed
• Includes coverage for Breast Pumps
Sterilization Procedures (Prior Authorization Required)
1. Vasectomy (Outpatient Only) Plan pays 100% *Plan pays 70%, Member pays 30%
2. Tubal Ligation (Traditional and with Fulguration)
Deductible does not apply to these benefits Participating Providers Non-participating Providers
when you go to a Participating Provider Deductible does not apply after Deductible is met
Annual Eye Exam
$20 Member Co-payment *Plan pays 70%, Member pays 30%
Once per member per plan year
Outpatient Physician Care & Services
1. Primary Care Visits $20 Member Co-Payment
2. Specialist Care Visits $40 Member Co-Payment
3. Voluntary Second Surgical Opinion $40 Member Co-Payment
4. Urgent Care Visits $50 Member Co-Payment
*Plan pays 70%, Member pays 30%
5. Mental Health Care and Substance Abuse Visits $20 Member Co-Payment
6. Home Health Care Visit (Prior Authorization Required) Plan pays 100%
7. Hospice Care in Guam only, maximum of $100 per day (Prior Authorization Required) Plan pays 100%
8. Routine Diagnostic Tests (X-ray, ultrasound, ECG, EEG, EMG & non-routine mammogram) $20 Member Co-Payment
9. Injections (Does not include those on the Specialty Drugs List) $20 Member Co-Payment
Emergency Care
$75 Member Co-payment plus any
(For an on and off island emergencies, plan must be contacted and advised within 48 hours)
$75 Member Co-payment difference in Eligible charges and
The co-payment will be waived if you are admitted to the hospital from the emergency room
billed charges
1. On/Off-Island emergency facility, physician services, laboratory, X-Rays
Ambulance Services (Ground transportation only) Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
* Plan pays 70% of eligible charges, Member pays 30% coinsurance of eligible charges plus any difference between eligible charges and billed charges. Eligible Charges for A full list of the Medical Exclusions can
Non-Participating Providers are limited to the lesser of actual charges or Medicare’s participating provider fee schedule in the geographic location where the service was be found in the Judiciary of Guam
rendered unless otherwise provided in the Agreement. The Covered Person pays any excess above Eligible Charges.
FY2021 Member Handbook.
**A separate deductible applies for services rendered by Non-Participating Providers
5 This handbook is designed to provide information about your Calvo’s SelectCare plan.
In the event of a discrepancy between this Handbook and the contract, the terms of the contract will prevail.Deductible does not apply to these benefits Participating Providers Non-participating Providers
when you go to a Participating Provider Deductible does not apply after Deductible is met
Prescription Drugs
Retail Pharmacy (30-day supply)
1. Formulary generic drugs per prescription unit Member pays 10%
2. Formulary brand name drugs per prescription unit Member pays 20%
3. Non-Formulary (Medically Necessary Only and Prior Authorization Required) Member pays 30%
Member pays 30% of Average
4. Specialty Drugs (Medically Necessary Only and Prior Authorization Required) Member pays 30%
Wholesale Price (AWP) plus
any difference between
Mail Order Pharmacy (90-day supply)
eligible and billed charges
1. Formulary generic drugs per prescription unit $0 Member Co-Payment
2. Formulary brand name drugs per prescription unit $0 Member Co-Payment
3. Non-Formulary (Medically Necessary Only and Prior Authorization Required) Member pays 30%
4. Specialty Drugs (Medically Necessary Only and Prior Authorization Required) Member pays 30%
Travel Benefit
• Prior authorization (written approval) and coordination is required from Plan prior to departure from Guam
• Applicable only to approved referrals for conditions not treatable on Guam Member pays all costs above $500
Not Covered
• Airfare and/or lodging expenses coverage for eligible members for approved specialty care visits, consultations, treatments Limited to once per plan year
and hospitalization services at Participating Providers in The Philippines or in Taiwan
• Executive check-ups, preventive services, primary care services and dental care do not qualify for this benefit
• Conditions and limitations apply as specified in the Member Handbook
Participating Providers Non-participating Providers
Deductible must be met for the following services after Deductible is met after Deductible is met
Acupuncture Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Allergy Testing
Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
$500 per member per plan year
Airfare Benefit to Centers of Excellence only
Plan pays 100% Not Covered
For members who meet qualifying conditions, Plan provides round trip airfare (Prior Authorization Required)
Ambulatory Surgi-center Care (Prior Authorization Required) Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Autism Spectrum Disorder Coverage
Referral from Primary Care Physician and Prior Authorization from Plan is required
Coverage is limited to the following maximums per member per benefit year: $50 Member Co-pay Not Covered
• $25,000 per benefit year for ages 16-21 years old
• $75,000 per benefit year for ages 0-15 years old
Services are subject to Plans benefit coverage guidelines and medical necessity
Blood & Blood Derivatives Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Breast Reconstructive Surgery (In accordance with 1998 W.H.C.R.A) Includes medically necessary anesthesia Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Cardiac Surgery Includes medically necessary anesthesia Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Cardiac Rehabilitation (Inpatient) Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Up to 30 days following bypass surgery or myocardial infarction
Cataract Surgery Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Includes lens implants. Outpatient Only. Includes medically necessary anesthesia
Chemotherapy Benefit Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Chiropractic Care Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Clinical Trials
Includes phases I-IV outpatient or inpatient clinic trials that are conducted in relation to treatment of cancer or other $40 Member Co-Payment *Plan pays 70%, Member pays 30%
life-threatening diseases or conditions as approved by the National Institute of Health or the National Cancer Institute
Complex Diagnostic Testing Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
MRI, CT scan, and other diagnostic procedures (Prior Authorization Required)
Durable Medical Equipment (DME)
The lesser amount between the Purchase or Rental of crutches, walkers, wheelchairs, hospital beds, suction machines, Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
CPAP machines, BPAP machines, insulin pumps, blood glucose monitors, oxygen and accessories when prescribed by a Physician of the total rental cost or purchase
(Prior Authorization Required)
Elective Surgery (Prior Authorization Required) Includes medically necessary anesthesia Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
End Stage Renal Disease / Hemodialysis Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
At Primary Care
Foot Care (subject to benefit limitations) $20 Member Co-Payment
*Plan pays 70%, Member pays 30%
Foot Care and Podiatry services At Specialist Care
$40 Member Co-Payment
Growth Hormone Therapy Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
* Plan pays 70% of eligible charges, Member pays 30% coinsurance of eligible charges plus any difference between eligible charges and billed charges. Eligible Charges for A full list of the Medical Exclusions can
Non-Participating Providers are limited to the lesser of actual charges or Medicare’s participating provider fee schedule in the geographic location where the service was be found in the Judiciary of Guam
rendered unless otherwise provided in the Agreement. The Covered Person pays any excess above Eligible Charges.
FY2021 Member Handbook.
**A separate deductible applies for services rendered by Non-Participating Providers
This handbook is designed to provide information about your Calvo’s SelectCare plan. 6
In the event of a discrepancy between this Handbook and the contract, the terms of the contract will prevail.Participating Providers Non-participating Providers
Deductible must be met for the following services after Deductible is met after Deductible is met
Hearing Aids
Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Maximum $1,000 per member per 24 months. Limited to 1 device every 3 years
Hearing Services Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Hospitalization & Inpatient Benefits
1. Room & Board for a semi-private room, intensive care, coronary care and surgery
2. All other inpatient hospital services including laboratory, x-ray, operating room, anesthesia and medication Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
3. Physician’s hospital services
4. Mental Health and Substance Abuse Admission
Hyperbaric Oxygen Therapy & Wound Care
Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Medically necessary (Prior Authorization Required)
Implants, Orthotics & Prosthetic Devices
Cardiac pacemakers, Intraocular lenses, artificial eyes, heart valves, orthopedic internal prosthetic devices, stents, stump hose, Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
cochlear implants, corrective orthopedic appliances and braces (Limitations apply, please refer to contract)
Inhalation Therapy Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Infertility Services Diagnosis of Infertility Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Maternity Care Labor and Delivery Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Nuclear Medicine (Prior Authorization Required) Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Occupational Therapy (Prior Authorization Required) Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Oral and Maxillofacial Surgery
Oral surgical procedures, limited to:
• Reduction of fractures of the jaws or facial bones
• Surgical correction of cleft lip, cleft palate or severe functional malocclusion
Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
• Removal of stones from salivary ducts
• Excision of leukoplakia or malignancies
• Excision of cysts and incision of abscesses when done as independent procedures
• Other surgical procedures that do not involve teeth or their supporting structures
Plan pays 80% for the first 20 visits
Physical Therapy (Prior Authorization Required) *Plan pays 70%, Member pays 30%
and 50% thereafter
Radiation Therapy (Prior Authorization Required) Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Reconstructive Surgery
• Surgery to correct a functional defect
Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
• Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm.
Examples of congenital anomalies are protruding ear deformities; cleft lip; cleft palate; birth marks; and webbed fingers and toes
Skilled Nursing Facility
Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Maximum 60 days per member per plan year (Prior Authorization Required)
Speech Therapy (Prior Authorization Required) Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Diagnostic Sleep Study (Pre-Certification Required) Plan pays 80%, Member pays 20% *Plan pays 70%, Member pays 30%
Additional Benefits: What the plan covers (Deductible does not apply) Participating Providers Non-participating Providers
WELLNESS BENEFITS
1. Wellness Programs at Guam SDA Wellness Center
Free Programs
• Nutrition Consultation Plan pays 100%
• Diabetes Self-Management Training Program
• Stop Smoking Program
• Childbirth Preparation Class
Discounted Programs Not Covered
• 7-day Shape Up Program
• 7-day Detox Program Discounts vary by program
• 7-day Advanced Detox Program
• NEWSTART Program
2. Health and Wellness Rewards
Plan Pays 100% at
• Up to $100 per plan year
Participating Providers
• Please refer to member brochure for Health and Wellness Rewards available
Plan pays 100% up to $200 per
Vision Benefit Plan pays 100% up to $200 member per 24 months through
Coverage for a pair of contact lenses or eyeglasses lens/frames – maximum of $200 per member per 24 months per member per 24 months reimbursement, which needs to
be submitted to Plan within
90 days from date of service
* Plan pays 70% of eligible charges, Member pays 30% coinsurance of eligible charges plus any difference between eligible charges and billed charges. Eligible Charges for A full list of the Medical Exclusions can
Non-Participating Providers are limited to the lesser of actual charges or Medicare’s participating provider fee schedule in the geographic location where the service was be found in the Judiciary of Guam
rendered unless otherwise provided in the Agreement. The Covered Person pays any excess above Eligible Charges.
FY2021 Member Handbook.
**A separate deductible applies for services rendered by Non-Participating Providers
7 This handbook is designed to provide information about your Calvo’s SelectCare plan.
In the event of a discrepancy between this Handbook and the contract, the terms of the contract will prevail.Judiciary of Guam
dental1000 Schedule of Benefits
What the Plan covers: Participating Providers Non-participating Providers
Subject to the Specific limitations which are contained in the Group Health Certificate
Diagnostic & Preventive Care
1. Caries Susceptibility Test
2. Exams – Includes Treatment Plan; once every 6 months
3. Fluoride Treatment – Annually for children up to age 19 70% of eligible charges
4. Prophylaxis – Cleaning & polishing of teeth; once every 6 months 100% of Eligible Expenses (Member pays excess above
5. Sealants – For permanent molars & pre-molars for children up to age 16 Eligible Expenses)
6. Space Maintainers - For children up to age 16 years; includes adjustments within 6 months of installation
7. Study Models
8. X-rays (Bite Wing); Maximum of 4 per Plan year
9. X-rays (Full Mouth); once every 3 years
Basic & Restorative Care
General Services
1. Emergency Care (during office hours)
2. Pulp Treatment
3. Routine Fillings
• Amalgam & Composite Resin
• Synthetic & Plastic (other than gold & porcelain)
Oral Surgery
1. Simple Extractions
2. Complicated Extractions 70% of eligible charges
3. Tooth Impactions 80% of Eligible Expenses (Member pays excess above
Eligible Expenses)
Periodontal Care
1. Periodontal Prophylaxis; Cleaning and polishing once every six months
2. Periodontal Treatment
General Anesthesia
• Includes Conscious Sedation and Nitrous Oxide
• Covered when recommended by attending physician
Pulpotomy & Root Canals/ Endodontic Surgery & Care
Major & Replacement Care
Fixed Prosthetics
1. Crowns and Bridges
2. Gold Inlays & Onlays
3. Replacement of Crown Restoration; limited once every 5 years 35% of eligible charges
50% of Eligible Expenses (Member pays excess above
Removable Prosthetics Eligible Expenses)
1. Full Dentures; once every 5 years
2. Partial Dentures; once every 5 years
3. Each Additional Tooth
4. Relines
5. Denture Repair
Coverage Maximums
Individual member annual maximum $1,000
Terms:
1. Unused balances are not transferable to the following year. A full list of the Medical Exclusions can
be found in the Judiciary of Guam
2. Charges for Non-participating Providers are limited to the lesser of actual charges or the usual, FY2021 Member Handbook.
customary and reasonable charge in the geographic location where the service was rendered, unless
otherwise provided in the agreement.
3. The covered member pays any excess above Eligible Charges.
4. Plan has no deductible.
5. There are no registration fees for visits to participating providers.
This handbook is designed to provide information about your Calvo’s SelectCare plan. 8
In the event of a discrepancy between this Handbook and the contract, the terms of the contract will prevail.Local Provider Options
9 This handbook is designed to provide information about your Calvo’s SelectCare plan.
In the event of a discrepancy between this Handbook and the contract, the terms of the contract will prevail.Our comprehensive provider network
offers choices to quality providers for you!
Local, National, and International access
to thousands of doctors, hospitals, dental and vision care providers
Off-Island Asia Provider Options
Philippines Taiwan Japan Hong Kong Korea
Philippines Taiwan Hong Kong
Cardinal Santos Medical Center China Medical University Hospital Gleneagles Hong Kong Hospital
Makati Medical Center Shin Kong Wu Ho-Su Memorial Hospital Hong Kong Adventist Hospital - Stubbs Road
Manila Doctor’s Hospital Taiwan Adventist Hospital
National Kidney and Transplant Institute
Korea
St. Luke’s Medical Center: Global City, Manila
Japan Samsung Medical Center
Kameda Medical Center
St. Luke’s Medical Center: Quezon City, Manila
Kameda Kyobashi Clinic
The Medical City: Clark Freeport Zone, Pampanga
The Medical City: Molo, Iloilo City
The Medical City: Pasig City, Manila
Off-Island U.S. Provider Options
Hawaii
Kapiolani Medical Center for Women & Children
Straub Clinic and Hospital
The Cancer Center of Hawaii
University Clinical Education Research Associates
A network that delivers great value and volume
With nearly 1,100,000 providers across the country,
California United Healthcare provides a network designed to help better
Doctor’s Medical Center of Modesto control costs and meet the unique needs of your employees.
Good Samaritan Hospital
Hawaii Long Beach Memorial Medical Center
St. Vincent Medical Center
White Memorial Medical Center
Advanced Urology Medical Group
Anaheim Global Medical Center
560 1,700+ 6,100+
Cedars-Sinai Medical Center
Centers of Convenience Hospitals
Chapman Global Medical Center Excellence Care Centers
Children’s Hospital of Los Angeles
Orange County Global Medical Center
South Coast Global Medical Center
St. John’s Health Center
USC
USC Norris Cancer Center 111K+ 1.1M+
California USC Verdugo Hills Hospital
Doctors and Health UnitedHealth Premium
Sharp Chula Vista Medical Center
Professionals Care Physicians
Sharp Coronado Hospital and Medical Center
Sharp Memorial Hospital Special Transplant Facilities
Optum/United Healthcare
Off-Island Provider: Center of Excellence Off-Island Provider
Care for Off-Island Services must be pre-approved by Calvo’s SelectCare
Participating providers may change from time to time, so please contact our office for any updates
This handbook is designed to provide information about your Calvo’s SelectCare plan. 10
In the event of a discrepancy between this Handbook and the contract, the terms of the contract will prevail.Providers: Participating Guam Doctors and Dentists
Providers may change from time to time, we encourage you to call our customer service department.
Doctors
Cardiology Gastroenterology Philips, Sherif Domalanta, Dina Surgery-Cardiac/ Thoracic
Giambartolome, Alessandro Farrell, Frank - VISITING Safa, Saied Fojas, Milliecor Yap, Alexander
Inaba, Yoichi Garcia, Antonio Surgery-General
Geriatrics Neurology
Kim, Byungsoo Garrido, John Bandy, Nicholas
Liu, Pei-Chang Carlos, Ramel
Prieto, Alejandro Linsangan, Gladys Cruz, Michael
Ouhadi, Faraz Hale, Justin
Quiros, Juan - VISITING Manaloto, Cristina Eusebio, Christian
Schroeder Jr., Edmund OB/GYN Santos, Edna
Wiedermann, Joseph Eusebio, Ricardo B.
Hematology Bez, Ellen Sarmiento, Dennis
Dermatology Friedman, Samuel Bieling, Friedrich Um, Michael
Go, Peter
LaTour, Donn - VISITING Helm, Joseph
Sanchez-Varela, Ana Bordallo, Annie U. Walker, Jasmine
Prodanovic, Edward - VISITING Im, Sunggeun
Gabel, Jeffrey
Yang, Hoseong Steve Infectious Disease Physical Medicine & Kobayashi, Ronald
Hirata, Greigh - VISITING
Medicine Rehabilitaion Leon Guerrero, Alexandra
E.N.T. (Otolaryngology) Magcalas, Edgardo
Jyung, Jin
Gaerlan, Maria Stella Li, Doris Sophia
Castro, Jerry Miller, Vanessa
Ursales, Anna Leigh Medina, Daniel
Ryu, David Sidell, Jonathan Podiatry
Yamamoto, Michelle Oh, Daniel
Shieh, Thomas Borja, Teresa
Endocrinology Internal Medicine Swena, Deborah Kim, Sungwook
Rahmani, Kia
Alford, Erika Sandy, Gisella
Agustin, Michael Todd, Rose Prins, Dustin
Rubio, Joel Saw, Eng
Alford, Erika Underwood, Teresa Sangalang, Melinda
Family Practice Ally, Insaf Silan, Noel Surgery-Hand & Microsurgery
Oncology
Adolphson, Arania Alvez, Laura Tutnauer, Philip Landstrom, Jerone
Au, Kin-Sing
Akimoto, Vincent Arcilla, Leopoldo Pulmonology/Critical Care Surgery-Neurological
Coty, Paul
Akoma, Ugochukwu Chang, Young Agustin, Michael Hayashida, Steven
Friedman, Samuel
Anderson, Mark Chenet, Alix Aguon, Joleen Nyame, Verrad
Guzman, Pablo
Arnott, Timothy Cruz, Jeffrey Gonzalez-Huertas, Jose Weingarten, David
Huang, Chen
Bryson, Julie Cruz, Olivia Hernandez, Elizabeth
Ko, Song-Chu Surgery-Plastic &
Campus, Hieu Duenas, Vincent A.
Sanchez-Varela, Ana Radiology Reconstructive
Cook-Hyunh, Mariana Guzman, Pablo
Cruz, Luis Inaba, Yoichi Ophthalmology Allen, Scott Fegurgur, John
Flores, Lisa Kang, Jiyeong Burton, Gregory P. Berg, Nathaniel Surgery Vascular
Frickel, Wendy Lim, Doris DeBenedictis, Marjorie Bocobo, George Eusebio, Ricardo
Galgo, Geoffrey Lim Jr., Johnny Flowers, Charles Khandelwal, Ashish Kobayashi, Ronald
Gerling, William Lizama, Florencio Larry T. Horio, Blake Lizama, Vincent
Hancock, William Magcalas, Edgardo Jack, Robert Mallikarjunappa Urology
Lee, Delores Nerves, Robert C. Lombard, Peter Martinez, Roberto Fenton, Ann
Loder, Bryce Osman, Sharleen Margalit, Eyal Nguyen, Tuan Petero, Virgilio
Lom, Jitka Ouhadi, Faraz Ng, Eugene - VISITING Packianathan, Xavier Wound Care
Lujan, Davina Preston, Donald Parks, David - VISITING Piana, Peachy Acuna, Edna
Manlucu, Luella Rubio, Joel Smith, Anthony Pomeranz, Steven
Mariano, Maria Safa, Saied Wresh, Robert Schneider, Michael
Miyagi, Shishin Samonte, Romeo Shay, Jeffery
Orthopedics
Namm, Julie Sistoza, Lilybeth Spak, Eric
Arafiles, Ruben
Nguyen, Hoa Van Taitano, John Ray Tan, Kenneth
Cunningham, Glenn
Nguyen, Luan Trinh, Tien Taylor, Laura
Galang, Carmelino
Raab, Jeremy Ursales, Anna Leigh Thorisson, Hjalti
Kim, Andrew
Richardson, Ian Villa, Eden Young, John
Robinson, Michael Yamamoto, Michelle Pain Management
Sleep Medicine
Samaniego, Maria Gaerlan, Maria Stella
Nephrology Barthlen, Gabriele
Santos, Patrick Alvez, Laura Pediatrics Lin, Shin Hao
Schroeder Jr., Edmund Dissadee, Mana Blancaflor, Maria Schumann, Richard
Terlaje, Ricardo Nerves, Robert C. Carrera, Yolanda
Thanapandian, Kamala Osman, Sharleen Del Rosario, Amanda
Dentists
General Dentistry Isa Dental Clinic Premier Dentistry Endodontics Periodontics
Brady, Timothy Island Dental Reflection Center Dental Care Premier Dentistry Gatewood, Robert
Family Dental Center Lee, Thomas K. Seventh Day Adventist Dental Rhim, Song
Fernandez, Michael Malabanan Jr., Ben Veloria, Tom S. Pediatric Dentistry Hayashi, Chie
GentleCare Dental Associates Mangilao Dental Clinic Yang, Robert J. Isa Dental Clinic
Hafa Adai Family Dental, P.C Ordot Dental Clinic Yasuhiro, Stanley Kim, Backhabwha
Harmon Loop Dental Office Paradise Smiles Dental Clinic Pediatric Dental Center
Providers marked with an asterisk (*) are Medicare Providers
Participating providers may change from time to time, so please contact our office for any updates
11 This handbook is designed to provide information about your Calvo’s SelectCare plan.
In the event of a discrepancy between this Handbook and the contract, the terms of the contract will prevail.Providers: Participating Clinics, Hospitals, Pharmacies and Services
Providers may change from time to time, we encourage you to call our customer service department.
Participating Clinics
Adult Health Care Clinic* Guam Foot Clinic* Hepzibah Family Medicine Clinic* OmniHealth Wound Care St. Anthony’s Clinic
American Medical Center* Guam Hearing Doctors* Isla Pediatrics & Hyperbaric Medicine St. Lucy’s Eye Clinic*
American Pediatric Clinic, LLC Guam Medical Care Island Cancer Center* One Love Pediatrics The Doctor’s Clinic*
Blue Ocean Medical Group Guam Medical Health Care Center Island Eye Center* Pacific Cardiology Consultants* The Neurology Clinic*
Byungsoo Kim, M.D.* Guam Medical Imaging Center* Island Foot Specialists* Pacific Hand Surgery Center* The Pediatric and Adolescent Clinic
Cancer Center of Guam, LLP* Guam Orthopedic Clinic* Island Surgical Center* Pacific Medical Group* The Weingarten Institute
Central Medical Clinic* Guam Radiology Consultants* Latte Stone Cancer Care* Pacific Radiology, Inc. for Neuroscience*
Center for Women's Health GRMC Specialty Care Center* Leopoldo Arcilla, M.D.* Pacific Retina Group, LLC* The Women’s Clinic
Dededo Polymedic Clinic Guam SDA Clinic* Lombard Health* Pacific Retina Specialists* Thomas Shieh, M.D.
Evergreen Health Center Guam Sleep Center* Marianas Footcare Clinic* Pacific Sleep Care Tumon Kidney Center*
Express Care Health & Guam Specialist Group, PLLC* Marianas Physicians Group Pacific Sleep Center Tumon Medical Office
Skin Care Center Guam Surgical Group* MDX Imaging* Pediatric & Asthma Clinic, PC Tumon Pediatric Clinic
Guam Adult & Pediatric Clinic Guam Surgicenter, LLC* Micronesia Medical and Renal Centers of Guam* U.S. Renal Care
Guam Behavioral Health & Guam Urology, LLC* Anesthesia Assoc., PLLC* Romeo Samonte, M.D.* Finegayan Dialysis*
Wellness Center* Hagatna MED Clinic* MPG Pediatrics, PC Sagua Managu U.S. Renal Care Sinajana Dialysis*
Guam Dermatology Institute Harmon Pediatrics Northern Region SDA Wellness Center United Family Medical Center
Guam Dialysis Center* Health Partners, LLC* Community Health Center Southern Region Young Chang, M.D.
Guam E.N.T., LLC* Health Services of the Pacific* Olivia Cruz, M.D. Community Health Center
Allied Services
Acupuncture Home Health Care Baza, Lisa Physical Therapy Radiology
Baik, Jong Sun Guam Visiting Nurses* Bellis, Kirk Bright, Kim Guam Medical Imaging Center*
Chong, Richard Health Services of the Pacific* Bordallo, Sandra Campos, Leonard Guam Radiology Consultants*
Yu, Jong Isla Home Infusion Chargualaf, Melissa Chan, Keith MDX Imaging*
Paradise Home Care Cristobal-Lujan, Hope Chong, Dae-II Pacific Radiology, Inc.*
Audiology Guilliot, Rosemarie Claros, Ryan The Doctor’s Clinic*
Koffend, Renee* Laboratory Hunterspeaks Organization Golez, Rolan*
Diagnostic Laboratory Services Kallingal, George Guam Regional Medical City* Sleep Center
Chiropractic & Bio Path* Leitheiser, Andrea Health Services of the Pacific* Guam Sleep Center*
Arthur, Steve - American Medical Center* Lizama, Tricia Kim, Justin* Pacific Sleep Care
Beckwith, Nicholas - Dededo Polymedic Clinic* Natividad, LisaLinda O’Connor, Shannon Pacific Sleep Center
Dimalanta, Albert J. - Express Care Health & Skin Care* Pangelinan, Rusell Panepucci, Christopher
Gregory, Barbara - GITC Bldg* Perez, Lilli Pagaduan, Marc Speech Pathology
Gregory, Robert W. - Guam Adult & Pediatric Clinic* Rapadas, Juan Santos, Isaias* Duenas, Nicole
Larkin, Gary - Guam Medical Rosario-Sanchez, Katrina Sibug, Mary Ann
Larkin, Lani F. Health Care Center* Santos, Jamela S.O.A.R. Physical Therapy
Larkin, Scott - Guam Medical Plaza* Swaddell, Joan
Martin, Francoise - IHP Medical Group* Tolentino, Doris
Miller, Gregory J.* - PeMar Place* In-Area Hospitals
Nicdao, Placido - Sagan Amot Pharmacy* Optical
White, Roderick - The Doctor’s Clinic* Agahan Optical
- Young Chang, M.D.* FHP Vision Center* Guam Memorial
Durable Medical Equipment
Guam Med* Mental Health
Garcia Optical
Ideal Optical
Hospital Authority
Health Services of the Pacific* Aguon, Risha Ideal Vision Center
Healthcare Specialties* Aquino, JoBeth Lombard Health* Guam Regional
Isla Home Infusion, Inc. Baleto, Jesse
Baza, Joleen
New 20/20 Vision Center Medical City
Medquest Medical Supply Seventh Day Adventist Eye Clinic*
Vision Express
Participating Guam Pharmacies
Community Pharmacy Guam Medical Pharmacy Mega Drugs Polymedic Pharmacy Benefits provided by:
- American Medical Center - Daily Plaza Bldg
(Tumon) Guam Rexall Drugs - Oka Plaza Building Sagan Amot Pharmacy
- Guam Adult & Pediatric Clinic Harmon Drugs - FHP Health Center Seventh Day Adventist
Evergreen Pharmacy & Supplies Minutes Rx Pharmacy Pharmacy
ITC Pharmacy
Pharmacy Benefits Manager
Express Med Pharmacy - ITC Building Oka Pharmacy Super Drug BIN: 003650 Processor Control: 64
- American Medical Center - Photo Town Plaza - Dededo Payless
(Mangilao) Pacific Healthcare Pharmacy - IHP Medical Group
K-Mart Pharmacy - Oka Payless
- Dededo Perezville Pharmacy - Maite Payless
- Yigo Payless
Providers marked with an asterisk (*) are Medicare Providers
Participating providers may change from time to time, so please contact our office for any updates
This handbook is designed to provide information about your Calvo’s SelectCare plan. 12
In the event of a discrepancy between this Handbook and the contract, the terms of the contract will prevail.$500 Travel Benefit
To be applied toward the cost of either (a) round trip airfare
between Guam and Manila, Philippines or Taiwan; (b) ground
transportation between the airport and the hospital or; (c)
lodging in Manila or in Taiwan.
The following requirements apply:
• Calvo’s SelectCare will reimburse members up to the $500
allowance under this travel benefit.
• One time, per member, per year.
• For pre-authorized, specialty care visits, consultations, treatments
and hospitalization at participating providers in the Philippines.
Applicable only to approved referrals for conditions not treatable on
Guam.
• Excludes emergencies, Preventive Services/Executive Check-ups,
home health, hospice, maternity and dental-related services.
• Cannot be used in conjunction with the Airfare Benefit.
• Members are responsible for making their travel arrangements.
Members are also responsible for any transportation and lodging
expenses in excess of $500 and any penalties/fees incurred due to
member changes.
Air Ambulance Discount
50% OFF
Air Ambulance
Services!
Air Ambulance Carrier
and Plan approval required.
Certain qualifying conditions apply.
Airfare Benefit
When certain critical conditions occur, you
may qualify for round trip airfare to include:
• The member needing care
• An escort to provide assistance
• A medical escort, if medically necessary
This benefit applies to our Center of Excellence Network
only. Pre-certification and Pre-approval is required.
13 This handbook is designed to provide information about your Calvo’s SelectCare plan.
In the event of a discrepancy between this Handbook and the contract, the terms of the contract will prevail.You can also read
