Pages 1--64 from Microsoft Word - Brochure Y2K.doc

A Fee for Service Plan with a Preferred Provider Organization and a Point of Service Product
Administered by the Blue Cross and Blue Shield Association

Who may enroll in this Plan All Federal employees and annuitants who are eligible to enroll in the FEHBP
Enrollment code for this Plan
101 High Option Self Only
102 High Option Self and Family
104 Standard Option Self Only
105 Standard Option Self and Family

Visit the OPM website at http www opm gov insure
and
our website at http www fepblue org

Authorized for distribution by the
United States Office of
Personnel Management
Retirement and
Insurance Service

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Blue Cross and Blue Shield Service Benefit Plan 2000
Table of Contents
Introduction 3

Plain Language 3
How to use this brochure 3
Section 1 Fee for Service Plans 4
Section 2 How we change for 2000 4
Section 3 How to get benefits 6
Section 4 What if we deny your claim or request for pre authorization 12
Section 5 Benefits 15
Section 6 How to file a claim 39
Section 7 General exclusions Things we don't cover 41
Section 8 Limitations Rules that affect your benefits 42
Section 9 Fee for Service Facts 47
Section 10 FEHB Facts 55
Department of Defense FEHB Demonstration Project 58
Inspector General Advisory Stop Health Care Fraud 59
Index 60
Summary of benefits 62
Premiums 64

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Blue Cross and Blue Shield Service Benefit Plan 2000
Introduction
Blue Cross and Blue Shield Service Benefit Plan
This brochure describes the benefits you can receive from the Blue Cross and Blue Shield Service Benefit Plan under its contract CS 1039 with the Office of Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law This

Plan is underwritten by Participating Blue Cross and Blue Shield Plans which administer this Plan on behalf of the Blue Cross and Blue Shield Association and are referred to as Local Plans in this brochure

This brochure is the official statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this brochure If you are enrolled for Self and Family coverage each eligible family member is also entitled to these
benefits Nothing anyone says can modify or otherwise affect the benefits limitations and exclusions of this brochure
Because OPM negotiates benefits and premiums annually they change each year This brochure describes the only benefits available to you under this Plan in 2000 Benefit changes are effective January 1 2000 and are shown on pages 4 5 You do not have a right to

benefits that were available before January 1 2000 unless those benefits are also contained in this brochure Premiums are listed at the end of this brochure

Plain language
The President and Vice President are making the Government's communication more responsive accessible and understandable to the public by requiring agencies to use plain language Health plan representatives and Office of Personnel Management staff have worked
cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary technical terms you and other personal pronouns active voice and short sentences

We refer to the Blue Cross and Blue Shield Service Benefit Plan as this Plan throughout this brochure even though in other legal documents you will see a plan referred to as a carrier
Sections one two four and ten are now in plain language as well as portions of sections three and eight We will rewrite the remaining sections of this brochure including the benefits section for year 2001 Please note that the format and organization of this brochure
have changed as well
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable

How to use this brochure
This brochure has ten sections Each section has important information you should read If you want to compare this Plan's benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make
comparisons easier
1 Fee for Service Plans FFS This Plan is a FFS plan Turn to this section for a brief description of Fee for Service plans and how they work

2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get benefits and how we operate
4 What if we deny your claim or request for pre authorization This section tells you what to do if you disagree with our decision not to pay for your claim or to deny your request for a service

5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find information about non FEHB benefits
6 How to file a claim Look here to find specific information on how to file claims with us
7 General exclusions Things we don't cover Look here to see benefits that we will not provide
8 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
9 Fee for Service Facts This section contains information about precertification protection against catastrophic expenses and a definitions section

10 FEHB Facts Read this for information about the Federal Employees Health Benefits FEHB Program

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Blue Cross and Blue Shield Service Benefit Plan 2000
Section 1 Fee for Service Plans
Fee for Service plans reimburse you or your provider for covered services They do not typically provide or arrange for health care Fee for Service plans let you choose your own physicians hospitals and other health care providers

The FFS plan reimburses you for your health care expenses usually on a percentage basis These percentages as well as deductibles methods for applying deductibles to families and the percentage of coinsurance you must pay vary by plan The type and extent of
covered services vary by plan There is a detailed explanation of the benefits we offer in this brochure you should read it carefully
This FFS plan offers a Preferred provider organization PPO arrangement This arrangement with health care providers gives you enhanced benefits or limits your out of pocket expenses

Section 2 How we change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copayment of 10 for all primary care office visits
changes This year you have a right to more information about this Plan care management our networks
facilities and providers
If you have a chronic or disabling condition or are in the second or third trimester of pregnancy and your provider is leaving our PPO network at our request without cause we will notify you You may

continue to receive our PPO level of benefits for your specialist's services for up to 90 days after you receive notice We will provide regular non PPO benefits for the specialist's services after the
90 day period expires
You may review and obtain copies of your medical records on request If you want copies of your medical records ask your health care provider for them You may ask that a physician amend a

record that is not accurate not relevant or incomplete If the physician does not amend your record you may add a brief statement to it If they do not provide you your records call us and we will
assist you
If you are over age 50 all FEHB plans cover a screening sigmoidoscopy every five years This screening is for colorectal cancer

Changes to this Your share of the High Option Blue Cross and Blue Shield Service Benefit Plan premium will increase by 4.3 for Self Only or 3.6 for Self and Family
Plan Your share of the Standard Option Blue Cross and Blue Shield Service Benefit Plan premium will
increase by 8.0 for Self Only or 7.2 for Self and Family
We have eliminated the 50 prescription drug deductible applicable to drugs obtained from retail pharmacies under both options

We no longer waive the copayment for prescription drugs obtained through the mail for members with Medicare Part B as primary payer Under High Option all members now pay 8 for generic
and 14 for brand name prescription drugs and supplies obtained through the Mail Service Prescription Drug Program Under Standard Option all members now pay 12 for generic and
20 for brand name prescription drugs and supplies obtained through the mail See pages 34 35
Under High Option we no longer waive or reduce the coinsurance for prescription drugs obtained from a retail pharmacy for members with Medicare Part B as primary payer and all members will

pay 15 PPA at Preferred retail pharmacies and 35 AWP at Non preferred retail pharmacies Previously when Medicare Part B was the primary payer the 15 PPA coinsurance at Preferred
pharmacies was waived and the 35 AWP coinsurance at Non preferred pharmacies was reduced to 15 AWP See pages 34 35

Under Standard Option you now pay 25 PPA at Preferred retail pharmacies and 45 AWP at Non preferred retail pharmacies Previously coinsurance was 20 PPA at Preferred retail
pharmacies and 40 AWP at Non preferred retail pharmacies See pages 34 35
Under Standard Option we no longer waive or reduce the coinsurance for prescription drugs obtained from a retail pharmacy for members with Medicare Part B as primary payer who are

confined to a nursing home Previously the 20 PPA coinsurance at Preferred retail pharmacies was waived and the 40 AWP coinsurance at Non preferred retail pharmacies was reduced to 20
AWP See pages 34 35

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Blue Cross and Blue Shield Service Benefit Plan 2000
Under Standard Option you now pay 10 PPA after the 200 calendar year deductible for covered professional services rendered by Preferred providers Obstetrical care rendered by
Preferred providers will continue to be paid in full Previously your coinsurance was 5 PPA for these services See pages 16 17 and 27

You now pay nothing after the associated office visit copayment for diagnostic and screening sigmoidoscopies when rendered by Preferred facilities or Preferred professionals on an outpatient
basis When rendered by Non preferred facilities or Non preferred professionals benefits will be provided under Other Medical Benefits for one screening sigmoidoscopy every five years at age 50
or over the visit charge associated with these screening sigmoidoscopies is not covered and for all medically necessary diagnostic sigmoidoscopies See pages 26 28 and 31

Coverage is now available for certain organ tissue transplant procedures for chronic lymphocytic leukemia and indolent or non advanced small cell lymphocytic lymphoma only when performed as
part of a clinical trial See pages 18 and 19
Under this Plan's Standard Option Point of Service POS program you now pay 10 for home office and clinic visits This includes the copayments for home visits during covered home health

care by nurses or home health aides as well as outpatient physical occupational and speech therapy Previously your copayment was 5 for these services See the POS addendum for your service area
for details
Under this Plan's Standard Option Point of Service POS program you now pay a 5 generic or a 15 brand name copayment for prescription drugs and supplies when you use a POS retail

pharmacy You now pay a 12 generic or a 20 brand name copayment for each prescription drug or refill when you use the mail service pharmacy Previously your copayments were 5 per generic
and 10 per brand name prescription obtained from a POS retail pharmacy and 12 per prescription obtained through the mail See the POS addendum for your service area for details

Mail Service Prescription Drug Program copayments are now included under the Catastrophic Protection Benefit as out of pocket expenses See page 49
Coverage is now available for diabetic education See page 29
Coverage is now available for immunizations for Lyme disease and Hepatitis See pages 26 28 and 31

Coverage is now available for cardiac rehabilitation services through case management under the flexible benefits option See pages 6 and 41
See pages 10 and 11 for additional information concerning Local Plans that do not have Participating providers or Member hospitals
The benefit descriptions on pages 15 35 now indicate what you pay

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Blue Cross and Blue Shield Service Benefit Plan 2000
Section 3 How to get benefits
How do I keep my
health care
expenses down FEHB plans are expected to manage their costs prudently All FEHB plans have cost containment You can help measures in place All fee for service plans include two specific provisions in their benefits
packages precertification of inpatient admissions and the flexible benefits option Some include managed care options such as PPO's to help contain costs

As a result of your cooperative efforts the FEHB Program has been able to control premium costs Please keep up the good work and continue to help keep costs down

Precertification Precertification evaluates the medical necessity of proposed admissions and the number of days required to treat your condition You are responsible for ensuring that the precertification
requirement is met except for routine maternity admissions You or your doctor must check with your Local Plan before being admitted to the hospital If that doesn't happen your Plan will reduce

benefits by 500 Be a responsible consumer Be aware of your Plan's cost containment provisions You can avoid penalties and help keep premiums under control by following the procedures
specified on pages 47 48 of this brochure
Flexible benefits Under the flexible benefits option the Local Plan has the authority to determine the most effective
option way to provide services The Local Plan may identify medically appropriate alternatives to traditional care and coordinate the provision of Plan benefits as a less costly alternative benefit

Alternative benefits are subject to ongoing review The Local Plan may decide to resume regular contract benefits at its sole discretion Approval of an alternative benefit is not a guarantee of any

future alternative benefits The decision to offer an alternative benefit is solely the Local Plan's and may be withdrawn at any time It is not subject to OPM review under the disputed claims process

PPO and Point of
Service POS PPO This Plan has established Preferred provider organization PPO arrangements You can receive

covered services from PPO providers at a reduced cost Be sure to look to see if there are PPO cost savings when you review the benefits described in this brochure The Local Plan or for pharmacies
PCS Health Systems Inc is solely responsible for the selection of PPO providers and any questions regarding PPO providers should be directed to the Local Plan or for pharmacies PCS Health
Systems Inc see pages 10 11 and 54 for more information Call your Local Plan to obtain the names of PPO providers and to verify continued participation as a PPO provider

PPO benefits apply only when you use a PPO provider Provider networks may be more extensive in some areas than others The availability of every specialty in all areas cannot be guaranteed If
no PPO provider is available or you do not use a PPO provider the standard non PPO benefits apply

POS This Plan offers a Point of Service POS program under Standard Option in the following Local Plan areas Connecticut Georgia Kansas Louisiana New Orleans area Massachusetts Minnesota
New Jersey New York areas served by the Empire Plan North Dakota Fargo area Ohio Cincinnati area and Oklahoma The POS program provides a higher level of benefits when

services are provided or referred by a primary care physician selected by the member while providing Standard Option Non preferred benefits for services received without a referral An
addendum and a POS selection form are available from the Local Plans in the areas noted above that outline service areas benefit levels and special requirements of the POS program

How much do I pay You must share the cost of some services These cost sharing measures include deductibles coinsurance and copayments These and other measures are described in more detail below
for services

Deductibles A deductible is the amount of expense you must incur for covered services and supplies before the Plan starts paying benefits for the expense involved A deductible is not reimbursable by the Plan
and benefits paid by the Plan do not count toward a deductible When a benefit is subject to a deductible only expenses allowable under that benefit count toward the deductible

Calendar year The calendar year deductible is the amount of expenses you must incur for covered services and supplies each calendar year before the Plan pays certain benefits The calendar year deductible is
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Blue Cross and Blue Shield Service Benefit Plan 2000
150 per person under High Option and 200 per person under Standard Option The calendar year deductible applies to all covered services and supplies except for certain Inpatient Hospital
Benefits Facility Benefits Outpatient Surgery Additional Benefits Prescription Drug Benefits Standard Option Dental Benefits or under High Option Surgical Benefits and Maternity
Benefits
If the Billed charge for services you receive is less than the remaining portion of your deductible you pay the Billed charge If the Billed charge is more than the remaining portion of your

deductible you pay the remaining portion and you and the Plan pay the stated percentage of the amount of the Covered charge remaining if any see the discussion of coinsurance below

If you change options in this Plan during the calendar year the amount of covered expenses already applied toward the deductible of your old option will be credited to the deductible of your new
option
Hospital admission The per admission deductible is the amount of covered hospital room and board expenses you must incur during each Non preferred hospital admission before the Plan pays benefits The per
admission deductible is 100 under High Option and 250 under Standard Option
Family limit There is a separate calendar year deductible of 150 per person under High Option and 200 per person under Standard Option Under a family enrollment the deductible is considered satisfied
and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reach 300 under High Option and 400 under

Standard Option
Coinsurance Coinsurance is the stated percentage of Covered charges you must pay after you have met any applicable deductibles The Plan will base this percentage on either the Billed charge or the
Allowable charge whichever is less For instance when under Standard Option this Plan pays 75 of the Allowable charge see Definitions for a covered service you are responsible for the

coinsurance which is 25 of the Allowable charge In addition you will be responsible for any excess charge over the Plan's Allowable charge when you use a Non participating physician or
pharmacy For example if a Non participating physician ordinarily charges 100 for a service but the Plan's Allowable charge NPA is 65 determined by using the greater of the Medicare
participating fee schedule amount for the service 65 or 80 of the Plan's usual customary and reasonable amount 80 of 80 64 the Plan will pay 75 of the Allowable charge 75 of
65 48.75 You must pay the 25 coinsurance of the Allowable charge 16.25 plus the difference between the Billed charge and the Allowable charge 35 for a total member
responsibility of 51.25
Remember if you use Preferred or Participating physicians and pharmacies your share of Covered charges after meeting any deductible is limited to the stated coinsurance amounts based on the

Allowable charge in most Local Plan areas see pages 10 and 11 for exceptions If you use Nonparticipating physicians or pharmacies your out of pocket costs will be higher as shown in the
example above
Your local Blue Cross and Blue Shield Plan negotiates payment arrangements with Preferred and Member hospitals and other facilities and with Preferred and Participating physicians and other

professional providers that result in overall cost containment The amounts these providers agree to accept as payment in full are generally but not always lower than the Billed charge see Definitions
for an explanation of Preferred and Member rates Preferred and Participating Provider Allowances and Billed charge under Covered charges For services of these providers your coinsurance will be
based on the lesser of the Billed charge or the negotiated amount that these providers have agreed to accept including any savings the Local Plan realizes through discounts that are known and that can
be accurately calculated at the time your claim is processed If you are age 65 or older and not enrolled in Medicare this may not apply see pages 46 and 47 If you use Non member facilities
for inpatient care the Plan will pay its percentage based on the Billed charge or Average charge see Definitions under Covered charges You will be responsible for the coinsurance calculated on the
Billed charge or Average charge and any excess charge over the Average charge
Copayments A copayment is the stated amount the Plan may require you to pay for a covered service such as 12 per generic prescription by mail or 12 per office visit charge at a Preferred physician For instance
when you visit a Preferred physician for a covered service after you pay the 12 copayment the Plan pays the remainder of the Preferred Provider Allowance PPA

For outpatient facility care and inpatient and outpatient mental conditions substance abuse care in Preferred and Member hospitals you are responsible for the least of the sum of the applicable per
day copayments the Billed charge or the Preferred or Member rate after you have met any

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Blue Cross and Blue Shield Service Benefit Plan 2000
applicable deductibles For example if you receive four days of inpatient mental condition care at a Member hospital for which your copayments are 1,000 4 x 250 the Billed charge is 900 and
the Member rate is 800 you will be responsible for the Member rate 800 For Non member facilities you will be responsible for the lesser of the sum of your copayments or the Billed charge

If provider waives If a provider routinely waives does not require you to pay your share of the charge for services
your share rendered the Plan is not obligated to pay the full percentage of the amount of the provider's original charge it would otherwise have paid A provider or supplier who routinely waives coinsurance

copayments or deductibles is misstating the actual charge This practice may be in violation of the law The Plan will base its percentage on the fee actually charged For example if the provider

ordinarily charges 100 for a service but routinely waives the 25 coinsurance the actual charge is 75 The Plan will pay 56.25 75 of the actual charge of 75

Lifetime maximums Under High and Standard Options benefits are limited to 100 per person per lifetime for one smoking cessation treatment program see page 30
Under High and Standard Options inpatient care for treatment of alcoholism and drug abuse is limited to one treatment program 28 day maximum per person per lifetime see page 25

When you change options within the Blue Cross and Blue Shield Service Benefit Plan you and any covered family members are entitled to new benefits subject to the deductibles limitations
exclusions and definitions of the new option Benefit amounts accrued under High Option or Standard Option are accumulated in a permanent record regardless of the number of enrollment
changes
Do I have to submit You usually do not have to submit claims to us if you use Preferred providers If you file a claim please send us all of the documents for your claim as soon as possible You must submit claims by
claims December 31 of the year after the year you received the service Either OPM or we can extend this deadline if you show that circumstances beyond your control prevented you from filing on time

Please see Section 6 How to file a claim for specific information you need to know before you file a claim with us

Who provides my In a Fee for Service plan you may choose any covered facility or provider
health care
Covered facilities Covered facility providers include Preferred Facility A facility that has an agreement with a local Blue Cross or Blue Shield Plan to

accept the Plan's Preferred rate for services to Plan members Contact your Local Plan to find out if the facility you are interested in is a Preferred facility

Member Facility A facility that has an agreement with a local Blue Cross or Blue Shield Plan to accept the Plan's Member rate for services to Plan members Contact your Local Plan to find out if
the facility you are interested in is a Member facility
Non Member Facility A facility that is not a Preferred or Member facility

Freestanding Freestanding Ambulatory Facility A freestanding facility which meets the following
ambulatory criteria
facilities 1 Your services are performed in an outpatient setting that is not generally considered an office or clinic for the private practice of a doctor or other professional

2 The facility contains permanent amenities and equipment primarily for the purpose of performing medical surgical and or renal dialysis procedures and

3 Your treatment will be provided by or under the supervision of doctors and or nurses and may include other ancillary professional services performed at the facility

Some examples of ambulatory facilities include freestanding ambulatory medical facilities ambulatory surgical centers freestanding surgi centers and freestanding dialysis centers In
addition we may at our discretion recognize any other like facilities as freestanding ambulatory facilities

Hospitals Hospital An institution or distinct part of an institution that 1 for compensation from its patients and on an inpatient basis is engaged primarily in providing diagnostic and therapeutic
facilities for surgical and medical diagnoses treatment and care of injured and sick persons by or under the supervision of a staff of licensed doctors of medicine M D or licensed doctors of

osteopathy D O 2 continuously provides 24 hour a day professional registered nursing R N services and 3 is not other than incidentally an extended care facility a nursing home
a place for rest an institution for exceptional children the aged drug addicts or alcoholics or a
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Blue Cross and Blue Shield Service Benefit Plan 2000
custodial or domiciliary institution which has as its primary purpose the furnishing of food shelter training or non medical personal services

College infirmaries are considered Non member hospitals In addition we may at our discretion recognize any institution located outside the 50 states and the District of Columbia as
a Non member hospital
Skilled nursing Qualified Skilled Nursing Facility A facility that
facilities 1 specializes in skilled care and meets Medicare's special qualifying criteria and 2 has the staff and equipment to provide skilled nursing care performed by or under the

supervision of licensed nursing personnel or skilled rehabilitation services such as physical therapy performed by or under the supervision of a professional therapist and other related
health services
The term qualified skilled nursing facility does not include any institution that primarily cares for and treats mental diseases

Cancer research Cancer Research Facility A facility that is 1 a National Cooperative Cancer Study Group
facilities institution that is funded by the National Cancer Institute NCI and has been approved by a Cooperative Group as a bone marrow transplant center 2 an NCI designated Cancer Center or

3 an institution that has an NCI funded peer reviewed grant to study allogeneic or autologous bone marrow transplants and blood stem cell transplant support

Others Others as set forth within the benefits description
How facilities See Definitions for an explanation of Preferred rate Member rate Non member rate Average
are paid charge and Billed charge under Covered charges

Covered providers Covered professional providers include Physician Doctors of medicine M D osteopathy D O dental surgery D D S medical

dentistry D M D podiatric medicine D P M and optometry O D when acting within the scope of their licenses are considered physicians

Attending Physician The physician who has responsibility for the care and treatment of the member on an inpatient basis A consulting physician who is an employee of the hospital in
which the member is an inpatient is not the attending physician
The following are considered covered providers when they perform covered services within the scope of their license or certification

Independent Laboratory A laboratory that is licensed under State law or where no licensing requirement exists is approved by the Local Plan
Qualified Clinical Psychologist A psychologist who 1 is licensed or certified in the state where the services are performed 2 has a doctoral degree in psychology or an allied degree if
in the individual state the academic licensing certification requirement for clinical psychologist is met by an allied degree or meets the requirements of the Carrier and 3 has met the clinical
psychological experience requirements of the individual State Licensing Board
Nurse Midwife A person who is certified by the American College of Nurse Midwives or is licensed or certified as a nurse midwife in states requiring licensure or certification

Nurse Practitioner Clinical Specialist A person who 1 has an active R N license in the United States 2 has a baccalaureate or higher degree in nursing and 3 is licensed or certified
as a nurse practitioner or clinical nurse specialist in states requiring licensure or certification

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Blue Cross and Blue Shield Service Benefit Plan 2000
Clinical Social Worker A social worker who 1 has a master's or doctoral degree in social work 2 has at least two years of clinical social work practice and 3 in states requiring
licensure certification or registration is licensed certified or registered as a social worker where the services are rendered

Nursing School Administered Clinic A clinic that is 1 licensed or certified in the state where the services are performed and 2 provides ambulatory care in an outpatient setting
primarily in rural or inner city areas where there is a shortage of physicians Services billed for by these clinics are considered outpatient office services rather than facility charges

Others as set forth within the benefits description
Coverage in Within States designated as medically underserved areas any licensed medical practitioner will be
medically treated as a covered provider for any covered services performed within the scope of that license For 2000 the States designated as medically underserved are Alabama Idaho Kentucky Louisiana
underserved Mississippi Missouri New Mexico North Dakota South Carolina South Dakota Utah and
areas Wyoming

How providers There are four types of Allowable charges the Preferred Provider Allowance PPA which applies
are paid to charges from Preferred professional providers and pharmacies the Participating Provider Allowance PAR which applies to charges from Participating professional providers the Nonparticipating

Provider Allowance NPA which applies to charges from Non participating professional providers and the Average Wholesale Price AWP which applies to charges from

Non preferred pharmacies See Definitions for an explanation of Allowable charges under Covered charges and Preferred Participating and Non participating physicians Most Preferred physicians
accept 100 of the PPA as payment in full see below for exceptions In most cases when you use a Preferred physician you are responsible for your coinsurance after any applicable deductible has
been met and are not responsible for any covered expense in excess of the PPA
Note Providers who contract with more than one Local Plan may be Preferred in one area and Participating in a different area To verify the status of a provider contact the Local Plan serving the

area where services are rendered
Participating physicians usually accept 100 of the Local Plan's PAR as payment in full That means when you use a Participating physician you are usually only responsible for your coinsurance

for covered services after any applicable deductible has been met and are not responsible for any covered expense in excess of the PAR In some Plan areas physicians who were formerly
Participating physicians are now Preferred physicians for the purposes of this Plan
In the following areas there are Preferred physicians but no Participating physicians for the purposes of either option of this Plan

Alabama Kansas Puerto Rico Alaska Mississippi South Carolina
California Blue Nevada Tennessee Shield
Connecticut New Hampshire Vermont Illinois New Jersey Wyoming

New York areas served by the Empire and Rochester
Plans Non participating physicians on the other hand may but are not required to accept the Local Plan's
NPA as payment in full These physicians may bill you up to their charge even after the Local Plan has paid its portion of your bill Members may be held responsible for any amounts over the NPA
in addition to applicable coinsurance amounts copayment amounts amounts applied to the calendar year deductible and noncovered services It is important that you are aware that your out ofpocket
costs may be higher when you use Non participating physicians

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Blue Cross and Blue Shield Service Benefit Plan 2000
In the following areas there are Preferred hospitals but no Member hospitals for the purposes of either option of this Plan
Alabama Nevada Pennsylvania areas Connecticut New Hampshire served by the
Illinois New Jersey Harrisburg Plan Kansas New York areas served by Rhode Island
Maine the Buffalo Empire Vermont Maryland Rochester and Wyoming
Montana Utica Watertown Plans

When this Plan pays In all Local Plan areas other than those described below Preferred physicians will accept 100 PPA
primary or secondary as payment in full and Participating physicians will accept 100 PAR as payment in full for covered services As a result you are only responsible for applicable coinsurance amounts copayment
benefits amounts amounts applied to the calendar year deductible and noncovered services Any balance above the applicable Allowable charge PPA or PAR billed by a Preferred or Participating

physician under either High Option or Standard Option should be brought to the attention of the Local Plan

Exception when this In Arizona if there is secondary coverage not administered by this Plan or other source of
Plan pays primary payment Preferred and Participating physicians are not obligated to accept the PPA or PAR as payment in full

Exceptions when this In Puerto Rico Preferred physicians can collect the difference between the Plan's payment and
Plan pays secondary the physician's charge In Montana Preferred and Participating physicians can collect the difference between the Plan's

payment and the physician's charge
In Pennsylvania and Utah the agreement described above applies only when the Local Plan makes a payment as the secondary payer to other coverage see pages 45 47

In the following areas Preferred and Participating physicians can collect the difference between the Plan's payment and the physician's charge except when this Plan pays secondary to other
Blue Cross and Blue Shield coverage
New York areas served South Carolina by the Rochester Plan Vermont

Rhode Island West Virginia

The above agreement applies only when the primary coverage is administered by the same Local Plan

Areas outside the The Washington DC Plan processes overseas claims see page 40 for instructions on submitting
United States and overseas claims at Preferred levels based on an Overseas Fee Schedule You are responsible for the difference between the Plan's payment and the provider's charge
Puerto Rico

What do I do if I'm First call our customer service department at the telephone number listed on the back of your
in the hospital when Service Benefit Plan identification card If you are new to the FEHB Program we will reimburse
I join this Plan your covered expenses If you are currently in the FEHB Program and are switching to us your former plan will pay for the hospital stay until

You are discharged not merely moved to an alternative care center or
You exhaust the benefits available from your former plan or
The 92 nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized

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Blue Cross and Blue Shield Service Benefit Plan 2000
What if I have a Please contact us if you believe your condition is chronic or disabling If it is you may be able to
serious illness and continue seeing your provider for up to 90 days after you receive notice that we are terminating our
my provider leaves contract with the provider unless the termination is for cause If you are in the second or third trimester of pregnancy you may continue to see your OB GYN until the end of your postpartum
the Plan or this Plan care
leaves the Program You may also be able to continue seeing your provider if your plan drops out of the FEHB Program
and you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic condition or are in the second or third trimester Your new plan will pay for or provide

your care for up to 90 days after you receive notice that your prior plan is leaving the FEHB Program If you are in your second or third trimester your new plan will pay for the OB GYN care
you receive from your current provider until the end of your postpartum care
If you continue seeing your specialist or OB GYN under these conditions your cost will be no more than you would normally pay for the services covered

How do I decide if a
service is Each Local Plan has a Medical Review department that makes these determinations after consulting
experimental or with internal or external experts or nationally recognized guidelines in a particular field or specialty
investigational For more detailed information contact your Local Plan at the telephone number located on the back of your identification card

Experimental or A drug device or biological product is experimental or investigational if the drug device or
investigational biological product cannot be lawfully marketed without approval of the U S Food and Drug Administration FDA and approval for marketing has not been given at the time it is furnished

Approval means all forms of acceptance by the FDA

A medical treatment or procedure or a drug device or biological product is experimental or investigational if 1 reliable evidence shows that it is the subject of ongoing phase I II or III

clinical trials or under study to determine its maximum tolerated dose its toxicity its safety its efficacy or its efficacy as compared with the standard means of treatment or diagnosis or
2 reliable evidence shows that the consensus of opinion among experts regarding the drug device or biological product or medical treatment or procedure is that further studies or clinical trials are
necessary to determine its maximum tolerated dose its toxicity its safety its efficacy or its efficacy as compared with the standard means of treatment or diagnosis

Reliable evidence shall mean only published reports and articles in the authoritative medical and scientific literature the written protocol or protocols used by the treating facility or the protocol s
of another facility studying substantially the same drug device or biological product or medical treatment or procedure or the written informed consent used by the treating facility or by another
facility studying substantially the same drug device or medical treatment or procedure

Section 4 What if we deny your claim or request for
pre authorization

What should I do Before you ask us to reconsider your claim you should first check with your provider or facility to be sure that the claim was filed correctly For instance did the provider use the correct procedure
before filing a code for the services performed surgery laboratory test X ray office visit etc Have your
disputed claim provider indicate any complications of any surgical procedures performed Your provider should also include copies of an operative or procedure report or other documentation that supports your
claim
If we deny your request for pre authorization or won't pay your claim you may ask us to reconsider our decision Your request must

1 Be in writing
2 Refer to specific brochure wording in explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were unable to make a timely request due to reasons beyond

your control
We have 30 days from the date we receive your reconsideration request to

1 Maintain our denial in writing
2 Pay the claim

12 12
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Blue Cross and Blue Shield Service Benefit Plan 2000
3 Approve your request for pre authorization or
4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30 days after we receive the additional information If we do not

receive the requested information within 60 days we will make our decision based on the information we already have

When may I ask OPM You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal
to review a denial OPM will determine if we correctly applied the terms of our contract when we denied your claim or request for service

What if I have a Call us at the telephone number located on the back of your identification card and we will expedite
serious or lifethreatening our review
condition
and you haven't
responded to my
request for preauthorization

What if you have If we expedite your review due to a serious medical condition and deny your claim we will inform
denied my claim for OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's health benefits Contracts Division I at 202 606 0727 between 8 a m and 5 p m Serious or lifethreatening
care and my condition conditions are ones that may cause permanent loss of bodily functions or death if they
is serious or lifethreatening are not treated as soon as possible

Are there other time You must write to OPM and ask them to review our decision within 90 days after we uphold our
limits initial denial or refusal You may also ask OPM to review your claim if 1 We do not answer your request within 30 days In this case OPM must receive your request

within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30 days In this case OPM must receive your request within 120 days of the date we asked you for

additional information
What do I send to Your request must be complete or OPM will return it to you You must send the following
OPM information 1 A statement about why you believe our decision is wrong based on specific benefit provisions

in this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills medical records and explanation of benefits EOB forms

3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to which claim

Who can make the Those who have a legal right to file a disputed claim with OPM are
request 1 Anyone enrolled in the Plan

2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled person's representative They must send a copy of the person's specific written consent with the

review request

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Blue Cross and Blue Shield Service Benefit Plan 2000
Where should I mail Send your request for review to Office of Personnel Management Office of Insurance Programs
my disputed claim to Contracts Division I P O Box 436 Washington D C 20044
OPM

What if OPM upholds OPM's decision is final There are no other administrative appeals If OPM agrees with our
the Plan's denial decision your only recourse is to sue If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third

year after the year in which you received the disputed services or supplies
What laws apply if I Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its
file a lawsuit review on the record that was before OPM when OPM made its decision on your claim You may recover only the amount of benefits in dispute

You or a person acting on your behalf may not sue to recover benefits on a claim for treatment services supplies or drugs covered by us until you have completed the OPM review procedure
described above
Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and
the Privacy Act us to determine if our denial of your claim is correct The information OPM collects during the review process becomes a permanent part of your disputed claims file and is subject to the

provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this information to support the disputed claim decision If you file a lawsuit this information will

become part of the court record

14 14
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Blue Cross and Blue Shield Service Benefit Plan 2000
Section 5 Benefits
Inpatient Hospital Benefits
What is covered The Plan provides coverage for inpatient hospital services as shown below

Precertification The medical necessity of your hospital admission must be precertified for you to receive full Plan benefits Emergency admissions not precertified must be reported within two business days
following the day of admission even if you have been discharged Otherwise the benefits payable will be reduced by 500 See pages 47 48 for details

Waiver This precertification requirement does not apply to persons whose primary coverage is Medicare Part A or another health insurance policy or when the hospital admission is outside the United
States For information on when Medicare is primary see page 43

Room and board The Plan provides coverage at the benefit levels indicated below for services provided by the
and following facilities when furnished and billed as regular inpatient hospital services
Other charges
High Option Standard Option

PPO Preferred You pay nothing for unlimited You pay nothing for unlimited hospitals days days

Member After you pay a 100 per After you pay a 250 per hospitals admission deductible you pay admission deductible you pay
nothing for unlimited days nothing for unlimited days
Non member In the United States and Puerto Rico you pay a 100 per admission hospitals deductible under High Option you pay a 250 per admission
deductible under Standard Option
In addition you pay 30 of the Non member rate see Definitions and any remaining balance after the Plan has made its payment

You pay nothing for facilities outside of the United States and Puerto Rico
Note You should be aware that some Preferred hospitals may have Non preferred providers on staff Following is a list of some of the frequently referred providers about whose Preferred status
you should inquire to help ensure that you receive your maximum benefits Radiologist Pathologist Anesthesiologist and Assistant Surgeon

Room and board Covered services are noted below
Semiprivate accommodations
Intensive care units

Private room A private room is covered only when the patient's isolation is required by law when the Carrier determines that isolation is medically necessary to prevent contagion or in Preferred and Member
hospitals when the hospital only offers private rooms
In noncovered private accommodations and in other noncovered accommodations the Plan pays the hospital's average daily rate for semiprivate accommodations which is determined by the Local

Plan Other hospital services are paid as shown above
Other hospital Operating recovery and other treatment rooms
charges Drugs and medical supplies

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider 15 When no PPO provider is available non PPO benefits apply 15
15 Page 16 17
Blue Cross and Blue Shield Service Benefit Plan 2000
X rays Magnetic Resonance Imagings MRIs laboratory and pathological services and machine diagnostic tests
Dressings splints plaster casts
Anesthetics and anesthesia service
Administration of blood and blood plasma see page 29 for coverage of blood and blood products

Pre admission testing recognized as part of the hospital admissions procedures
Limited benefits

Hospitalization for The Plan pays for room and board and other hospital services for hospitalization in connection with
dental work dental procedures only when a nondental physical impairment exists that makes hospitalization necessary to safeguard the health of the patient

Chemotherapy Chemotherapy and or radiation therapy when supported by allogeneic or autologous bone marrow
radiation therapy transplants or blood stem cell transplant support is only covered for specific diagnoses see Organ tissue transplants and donor expenses under Surgical Benefits on pages 17 20

Related benefits
Outpatient hospital See pages 26 27 for outpatient hospital care benefits and outpatient surgery facility care benefits
benefits

Surgical benefits See pages 17 20 for surgical benefits when provided or ordered and billed by a physician
Other charges See Other Medical Benefits for coverage of blood drugs and ambulance transport services
Inhospital The Plan provides coverage at the benefit levels indicated below for the following nonsurgical
physician care services provided or ordered and billed by a physician High Option Standard Option

PPO Preferred You pay 5 PPA After you pay the 200 calendar physicians year deductible you pay 10
PPA
Participating You pay 20 PAR After you pay the 200 calendar physicians year deductible you pay 25

PAR
Nonparticipating You pay 20 NPA You are After you pay the 200 calendar also responsible for the year deductible you pay 25

physicians difference between the Plan's NPA You are also responsible payment and the physician's for the difference between the
actual charge Plan's payment and the physician's actual charge

See Definitions for an explanation of Preferred Participating and Non participating physicians and PPA PAR and NPA under Covered charges
Medical care by the attending physician on days covered by Inpatient Hospital Benefits
Intensive physician care by the attending physician for treatment of a condition other than that for which surgical or maternity care is required

Consultations when requested by the attending physician not including routine radiological and staff consultations required by hospital rules and regulations
Concurrent care see Definitions
Physical therapy when provided by a physician other than the attending physician

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider
16 When no PPO provider is available non PPO benefits apply 16
16 Page 17 18
Blue Cross and Blue Shield Service Benefit Plan 2000
What is not Room and board and inhospital physician care when in the Carrier's judgment a hospital admission or portion of an admission is one of the following types
covered Custodial care see Definitions

Convalescent care or a rest cure
Domiciliary care provided because care in the home is not available or is unsuitable
Inpatient private duty nursing
Not medically necessary i e for services that did not require the acute hospital inpatient overnight setting but could have been provided in a physician's office the outpatient

department of a hospital or some other setting without adversely affecting the patient's condition or the quality of medical care rendered Some examples are

admissions for or consisting primarily of observation and or evaluation that could have been provided safely and adequately in some other setting e g physician's office
admissions primarily for diagnostic studies X rays Magnetic Resonance Imagings MRIs laboratory and pathological services and machine diagnostic tests that could have been
provided safely and adequately in some other setting e g outpatient department of a hospital or physician's office

If a hospital admission is determined to be one of the types listed above the Plan will pay benefits for services or supplies other than room and board and inhospital physician care at the level at which
they would have been covered if provided in some other setting

Surgical Benefits
What is covered The Plan provides coverage at the benefit levels indicated below except as noted for the following services provided or ordered and billed by a physician
High Option Standard Option
PPO Preferred You pay 5 PPA After you pay the 200 calendar physicians year deductible you pay 10

PPA
Participating You pay 20 PAR After you pay the 200 calendar physicians year deductible you pay 25

PAR
Nonparticipating You pay 20 NPA You are After you pay the 200 calendar also responsible for the year deductible you pay 25
physicians difference between the Plan's NPA You are also responsible payment and the physician's for the difference between the
actual charge Plan's payment and the physician's actual charge

See Definitions for an explanation of Preferred Participating and Non participating physicians and PPA PAR and NPA under Covered charges

Surgical services Operative or cutting procedures including treatment of fractures and dislocations surgical sterilization and normal pre and post operative care by the operating physician
Diagnostic procedures such as endoscopies and biopsies
Treatment of burns
Surgical correction of congenital anomalies see Definitions

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider 17 When no PPO provider is available non PPO benefits apply 17
17 Page 18 19
Blue Cross and Blue Shield Service Benefit Plan 2000
Extraction or reinfusion of bone marrow blood stem cells or cord blood as a source of stem cells as part of an allogeneic or autologous bone marrow transplant or blood stem cell transplant
support procedure including marrow harvesting in anticipation of a covered autologous bone marrow transplant for patients diagnosed at the time of harvesting with one of the conditions
listed on pages 18 19 The collection processing storage and distribution of cord blood must be performed by a cord blood bank approved by the FDA Expenses for storage of harvested
bone marrow blood stem cells or cord blood as a source of stem cells are not covered unless the covered transplant has already been scheduled

When unusual circumstances require removal of casts or sutures by a physician other than the one who applied them the Local Plan may determine that a separate allowance is payable
Surgical correction of amblyopia and strabismus
Multiple surgical When multiple or bilateral surgical procedures that add time or complexity to patient care are
procedures performed during the same operative session the Plan pays these multiple bilateral or incidental surgical combined procedures on the basis of the Allowable charge that is determined by the Local

Plan The Plan determines which procedure is primary and which procedures are secondary tertiary etc and provides a reduced allowance for the non primary procedures

Assistant surgeon Surgical assistance by a physician if required by the complexity of the surgical procedure
inpatient outpatient

Anesthesia Anesthesia service including acupuncture when requested by the attending physician and
inpatient outpatient performed by a certified registered nurse anesthetist CRNA or a physician other than the operating physician or the assistant for covered surgical services CRNAs are reimbursed at the payment

levels indicated above for Participating and Non participating physicians

Organ tissue
transplants and donor
expenses

What is covered The following human organ tissue transplant procedures
Allogeneic bone marrow transplant and allogeneic cord blood stem cell transplant from related or unrelated donors for 1 Advanced neuroblastoma 2 Infantile malignant osteopetrosis

3 Severe combined immunodeficiency 4 Wiskott Aldrich syndrome 5 Mucopolysaccharidosis e g Hunter Hurler's Sanfilippo Maroteaux Lamy variants
6 Mucolipidosis e g Gaucher's disease metachromatic leukodystrophy adrenoleukodystrophy 7 Severe or very severe aplastic anemia 8 Thalassemia major
homozygous beta thalassemia and 9 Sickle cell anemia
Allogeneic bone marrow transplant allogeneic cord blood stem cell transplant from related or unrelated donors and allogeneic peripheral blood stem cell transplant for 1 Acute lymphocytic

or non lymphocytic i e myelogenous leukemia 2 Advanced Hodgkin's lymphoma 3 Advanced non Hodgkin's lymphoma 4 Chronic myelogenous leukemia and 5 Advanced
forms of myelodysplastic syndromes
Autologous bone marrow transplant and autologous peripheral blood stem cell transplant collectively referred to as autologous stem cell support for 1 Acute lymphocytic or

nonlymphocytic i e myelogenous leukemia 2 Advanced Hodgkin's lymphoma 3 Advanced non Hodgkin's lymphoma 4 Advanced neuroblastoma 5 Testicular Mediastinal
Retroperitoneal and Ovarian germ cell tumors and 6 Multiple myeloma
Allogeneic bone marrow transplant syngeneic bone marrow transplant and allogeneic peripheral blood stem cell transplant for 1 Multiple myeloma 2 Chronic lymphocytic

leukemia and 3 early stage indolent or non advanced small cell lymphocytic lymphoma and autologous bone marrow transplant and autologous peripheral blood stem cell transplant
collectively referred to as autologous stem cell support for 1 Breast cancer 2 Epithelial ovarian cancer 3 Chronic myelogenous leukemia 4 Chronic lymphocytic leukemia and 5
early stage indolent or non advanced small cell lymphocytic lymphoma only when performed as part of a clinical trial that meets the requirements noted in the Limitations below and is
conducted at a Cancer Research Facility see page 9

18 The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider When no PPO provider is available non PPO benefits apply 18
18 Page 19 20
Blue Cross and Blue Shield Service Benefit Plan 2000
In the event no non randomized clinical trials meeting the requirements set forth below are available at Cancer Research Facilities for a member eligible for such clinical trials the Plan
will make arrangements for the transplant to be provided at another Plan designated transplant facility

Related services or supplies provided to the recipient are covered including chemotherapy and or radiation therapy when supported by allogeneic or autologous bone marrow transplants or blood
stem cell transplant support and drugs or medications administered to stimulate or mobilize stem cells for the transplant procedures described above

Single or double lung transplants for the following end stage pulmonary diseases 1 Pulmonary fibrosis 2 Primary pulmonary hypertension and 3 Emphysema
Double lung transplant for end stage cystic fibrosis
Cornea Heart Heart lung Small bowel Kidney Liver Pancreas

Related medical and hospital expenses of the donor are covered
Limitations Prior approval by the Local Plan of the procedure and the facility is required for bone marrow
cord blood stem cell and peripheral blood stem cell transplant support procedures heart heartlung liver lung pancreas and small bowel transplants see page 48

For the bone marrow transplant procedures and related services or supplies covered only through clinical trials
1 Prior approval by the Carrier is required see page 48
2 The clinical trial must be reviewed and approved by the Institutional Review Board of the Cancer Research Facility where the procedure is to be delivered and

3 The patient must be properly and lawfully registered in the clinical trial meeting all the eligibility requirements of the trial

What is not covered Services or supplies for or related to artificial or human organ tissue transplants for any diagnosis not specifically listed as covered Related services or supplies for noncovered procedures including
chemotherapy and or radiation therapy when supported by allogeneic or autologous bone marrow transplants cord blood stem cell transplants from related or unrelated donors or peripheral blood

stem cell transplant support drugs or medications administered to stimulate or mobilize stem cells for transplant and all other services or supplies which would not be medically necessary or
appropriate but for the noncovered procedure
Oral and Limited to the following surgical procedures
maxillofacial Excision of tumors and cysts of the jaws cheeks lips tongue roof and floor of mouth when
surgery pathological examination is required Surgery needed to correct accidental injuries see Definitions to jaws cheeks lips tongue roof

and floor of mouth
Excision of exostoses of jaws and hard palate
External incision and drainage of cellulitis
Incision and surgical treatment of accessory sinuses salivary glands or ducts
Reduction of dislocations and excision of temporomandibular joints
Removal of impacted teeth

Mastectomy surgery Women who undergo mastectomies may at their option have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure A patient and her
attending physician may decide whether to have breast reconstruction surgery following a mastectomy and whether surgery on the other breast is needed to produce a symmetrical appearance

see page 20

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider 19 When no PPO provider is available non PPO benefits apply 19
19 Page 20 21
Blue Cross and Blue Shield Service Benefit Plan 2000
Reconstructive Benefits will be provided for
surgery Treatment to restore the mouth to a pre cancer state

Breast reconstruction surgery following a mastectomy including surgery to produce a symmetrical appearance on the other breast Benefits will be provided for all stages of breast

reconstruction following a mastectomy including treatment of any physical complications including lymphedemas and for breast prostheses including surgical bras and replacements

Related benefits
Outpatient surgery Outpatient surgical services billed for by a facility are covered under Other Medical Benefits See
facility care benefits page 27

What is not covered Cosmetic surgery see Definitions unless required for a congenital anomaly or to restore or correct a part of the body which has been altered as a result of accidental injury disease or
surgery
Radial keratotomy and other refractive surgeries
Services for or related to reversal of surgical sterilization

20 The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider When no PPO provider is available non PPO benefits apply 20
20 Page 21 22
Blue Cross and Blue Shield Service Benefit Plan 2000
Maternity Benefits

What is covered The Plan provides coverage at the benefit levels indicated below for services provided by the following facilities when furnished and billed as regular inpatient hospital services The mother at her option may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a
cesarean delivery Inpatient stays will be extended if medically necessary

Inpatient
hospital

Precertification Precertification is not required for maternity admissions for routine deliveries However if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a
cesarean section your physician or the hospital must contact the Local Plan for certification of additional days The Plan will not pay for charges incurred on any extra days that are not medically
necessary See pages 47 48 for details
High Option Standard Option
PPO Preferred You pay nothing for unlimited You pay nothing for unlimited hospitals days days

Member After you pay a 100 per After you pay a 250 per hospitals admission deductible you pay admission deductible you pay
nothing for unlimited days nothing for unlimited days
Non member In the United States and Puerto Rico you pay a 100 per admission hospitals deductible under High Option you pay a 250 per admission
deductible under Standard Option
In addition you pay 30 of the Non member rate see Definitions and any remaining balance after the Plan has made it's payment

You pay nothing for facilities outside of the United States and Puerto Rico

Covered services are noted below
Room and board Room and board and other hospital services See Inpatient Hospital Benefits for a description of all covered services and payment levels for Non member hospitals

Private room A private room is covered only when the patient's isolation is required by law when the Carrier determines that isolation is medically necessary to prevent contagion or in Preferred and Member
hospitals when the hospital only offers private rooms
In noncovered private accommodations and in other noncovered accommodations the Plan pays the hospital's average daily rate for semiprivate accommodations which is determined by the Local

Plan Other hospital services are paid as shown above
Bassinet and nursery Hospital bassinet or nursery charges for days in which both the mother and newborn are confined in the hospital are considered as expenses of the mother and not expenses of the child When a

newborn requires definitive treatment including incubation charges by reason of prematurity or evaluation for medical or surgical reasons during or after the mother's confinement the newborn is

considered a patient in his or her own right and a separate per admission deductible if applicable applies Expenses of the newborn including circumcision are eligible for benefits only if the child
is covered by a Self and Family enrollment See page 48 for information on requesting additional days for a covered newborn confined beyond the mother's discharge date

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider 21 When no PPO provider is available non PPO benefits apply 21
21 Page 22 23
Blue Cross and Blue Shield Service Benefit Plan 2000
Other charges Operating recovery and other treatment rooms
Drugs and medical supplies
Other covered ancillary services

Outpatient care Outpatient hospital care for delivery including care in freestanding ambulatory facilities including birthing centers is covered as described under Other Medical Benefits Outpatient surgery Facility
care benefits see page 27
Note When you use Preferred facilities benefits for obstetrical care including prenatal testing are provided in full not subject to the calendar year deductible or copayment

Professional care The Plan provides coverage at the benefit levels indicated below for services provided or ordered and billed by a physician or nurse midwife
High Option Standard Option
PPO Preferred You pay nothing You pay nothing physicians

Participating You pay 20 PAR After you pay the 200 calendar physicians Nurse year deductible you pay 25
midwives PAR
Non participating You pay 20 NPA You are After you pay the 200 calendar physicians Nurse also responsible for the year deductible you pay 25

midwives difference between the Plan's NPA You are also responsible payment and the physician's for the difference between the
actual charge Plan's payment and the physician's actual charge

See Definitions for an explanation of Preferred Participating and Non participating physicians and PAR and NPA under Covered charges

Obstetrical care Physician care for pregnancy including related conditions and resulting childbirth or miscarriage
Services of a licensed or certified nurse midwife for pre and post partum care and delivery
Anesthesia services services of a nurse anesthetist and surgical assistance as described under Surgical Benefits

Related benefits
Contraceptive Intrauterine devices IUDs Norplant Depo Provera diaphragms and oral contraceptives
devices obtained from a physician are covered at the levels indicated on page 17 when obtained from a facility they are covered at Other Medical Benefit levels see page 27
and drugs IUDs Norplant Depo Provera diaphragms and oral contraceptives dispensed by a retail pharmacy are covered as prescription drugs see page 34

Oral contraceptives are also covered under the Mail Service Prescription Drug Program see page 34

Diagnosis and Diagnosis and treatment of infertility are covered at the benefit levels indicated on page 17 related
treatment of prescription drugs are covered under Prescription Drug Benefits see pages 34 35 see exclusion below for Assisted Reproductive Technology ART procedures
infertility

Prenatal testing Prenatal testing is covered at the benefit levels shown above and on page 27

22 The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider When no PPO provider is available non PPO benefits apply 22
22 Page 23 24
Blue Cross and Blue Shield Service Benefit Plan 2000
Voluntary Sterilization procedures see page 17 for benefits for surgical sterilization
sterilization

Well child care Well child care is covered under Additional Benefits see page 31
For whom Benefits are payable under Self Only enrollments and for family members under Self and Family enrollments

What is not covered Assisted Reproductive Technology ART procedures such as artificial insemination in vitro fertilization embryo transfer and GIFT as well as services and supplies related to ART
procedures including sperm banking
Reversal of voluntary sterilization
Contraceptive devices except as specifically described above

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider 23 When no PPO provider is available non PPO benefits apply 23
23 Page 24 25
Blue Cross and Blue Shield Service Benefit Plan 2000
Mental Conditions Substance Abuse Benefits
What is covered The Plan provides coverage at the benefit levels indicated below for services provided by the following facilities and professionals when furnished and billed as regular inpatient hospital
services

Mental conditions Note Please check with your Local Plan and or PPO directory for listings of Preferred facilities and contracted professional providers

Inpatient care
Precertification The medical necessity of your admission to a hospital or other covered facility must be precertified for you to receive full Plan benefits Emergency admissions must be reported within two business
days following the day of admission even if you have been discharged Otherwise the benefits payable will be reduced by 500 See pages 47 48 for details

Hospital care High Option Standard Option
PPO Preferred You pay a 75 per day You pay a 150 per day hospitals copayment for up to 120 days copayment for up to 100 days

you pay all charges thereafter you pay all charges thereafter
Member You pay a 150 per day You pay a 250 per day hospitals copayment for up to 120 days copayment for up to 100 days

you pay all charges thereafter you pay all charges thereafter
Non member You pay a 300 per day You pay a 400 per day hospitals copayment for up to 120 days copayment for up to 100 days
you pay all charges thereafter you pay all charges thereafter In addition you pay the In addition you pay the
difference between the Plan's difference between the Plan's payment and the provider's payment and the provider's
actual charge actual charge
After you pay the per day copayments the Plan pays the remainder of the Preferred rate Member rate or Non member rate in excess of the sum of your copayments In Preferred and Member
hospitals in some instances when the Preferred or Member rate or the Billed charge is less than the sum of your copayments you will be responsible only for the lowest amount In Non member
hospitals in some instances the Average charge may be less than the sum of your copayments
See the definition of Covered charges for an explanation of Preferred rate Member rate Nonmember rate Billed charge and Average charge See also the discussion of copayments on pages 78

Covered services include room and board and other hospital services see Inpatient Hospital Benefits for a description of all covered services
Inpatient visits The Plan provides coverage at the benefit levels indicated below for inpatient mental conditions and substance abuse professional care rendered by Participating and Non participating providers
High Option Standard Option
After you pay the 150 calendar year After you pay the 200 calendar year deductible you pay 20 of the deductible you pay 40 of the

Allowable charge see Definitions Allowable charge see Definitions

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider
24 When no PPO provider is available non PPO benefits apply 24
24 Page 25 26
Blue Cross and Blue Shield Service Benefit Plan 2000
Outpatient The Plan pays all covered outpatient care including related services and supplies such as
care psychological testing for the treatment of a mental condition including substance abuse as follows
Facility care High Option Standard Option

After you pay the 150 calendar After you pay the 200 calendar year deductible you pay the year deductible you pay the

following copayments following copayments
PPO Preferred You pay 10 You pay 25 facilities

Member You pay 50 You pay 100 facilities
Non member You pay 100 You pay 150 facilities

These copayments will be applied per facility per day not per service After meeting the deductibles you will be responsible for the lesser of the stated copayment or the Billed charge s If
Preferred or Member facilities are available and utilized you will be responsible for the lesser of the stated copayments the Billed charge s or the Preferred or Member rate at the time your claim is
processed
Professional care The Plan provides coverage at the benefit levels described below for outpatient mental conditions and substance abuse professional care rendered by Participating and Non participating providers

High Option Standard Option
After you pay the 150 calendar year After you pay the 200 calendar year deductible you pay 30 of the deductible you pay 40 of the

Allowable charge see Definitions Allowable charge see Definitions

Therapy Outpatient visits are available up to 50 visits under High Option and 25 visits under Standard Option per person per calendar year for

Individual or group therapy or combination of individual and group therapy up to two hours per day including collateral visits with members of the patient's immediate family provided by
a physician qualified clinical psychologist psychiatric nurse or clinical social worker
Day night hospital services sometimes called partial hospitalization

The number of visits for which you receive reimbursement will be reduced if these services are used to meet part or all of your calendar year deductible

Substance abuse
Inpatient care The Plan provides benefits for the inpatient treatment of alcoholism and drug abuse at the levels indicated on the previous page for hospital care and inpatient visits for mental conditions care

Treatment is also payable in a freestanding alcoholism facility approved by the Local Plan

Lifetime maximum Inpatient care for the treatment of alcoholism and drug abuse is limited to one treatment program 28 day maximum per lifetime under High and Standard Options

Outpatient care The Plan provides benefits for outpatient facility and professional care for the treatment of substance abuse at the benefit levels indicated above Outpatient visits accrue toward the visit limits described
above

What is not covered Marital family educational or other counseling or training services Services rendered or billed by a school or halfway house or a member of its staff
Psychoanalysis or psychotherapy credited toward earning a degree or furtherance of education or training regardless of diagnosis or symptoms that may be present

Services and supplies that are not medically necessary see Definitions and General Exclusions

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider 25 When no PPO provider is available non PPO benefits apply 25
25 Page 26 27
Blue Cross and Blue Shield Service Benefit Plan 2000
Other Medical Benefits

What is covered Except as noted after any applicable deductibles and copayments have been met the Plan pays the following
Outpatient High Option Standard Option
facility care After you pay the 150 calendar After you pay the 200 calendar year deductible you pay the year deductible you pay the

following copayments following copayments
PPO Preferred You pay 10 You pay 25 facilities

Member You pay 50 You pay 100 facilities
Non member You pay 100 You pay 150 facilities

These copayments will be applied per facility per day not per service After meeting the deductible you will be responsible for the lesser of the stated copayments or the Billed charge s If Preferred
or Member facilities are available and utilized you will be responsible for the lesser of the stated copayments the Billed charge s or the Preferred or Member rate at the time your claim is
processed
Covered services 1 when furnished by the hospital outpatient department ordered by a physician and billed by a hospital or 2 for renal dialysis when furnished and billed by a freestanding

ambulatory facility see Facilities and Other Providers are as follows
Diagnostic X rays Magnetic Resonance Imagings MRIs laboratory and pathological services and machine
services diagnostic tests Certain diagnostic cancer tests are covered differently when provided by a Preferred facility see page 31

Preventive In Member and Non member facilities each cervical cancer screening mammogram for breast
services cancer screening fecal occult blood test for colorectal cancer screening sigmoidoscopy for colorectal cancer screening PSA Prostate Specific Antigen test for prostate cancer screening

tetanus diphtheria Td booster and immunization for influenza pneumonia and Lyme disease is paid as described above See page 28 for the screening schedules related to these tests and

immunizations for Member and Non member facilities and for Participating and Non participating providers These services are covered differently when you use Preferred providers see page 31

Other Radiation therapy chemotherapy and renal dialysis chemotherapy and or radiation therapy
outpatient when supported by allogeneic or autologous bone marrow transplants or blood stem cell
services transplant support is covered only for those covered conditions as described under Organ tissue transplants and donor expenses under Surgical Benefits on pages 18 19

Physical occupational and speech therapy for visit limitations see page 30 Allergy tests surveys and injections blood as described under Miscellaneous services on

page 29 and prescription drugs billed for by the facility
Hepatitis immunizations for patients with increased risk or family history Hospital services in connection with dental procedures only when a nondental physical

impairment exists that makes hospitalization necessary to safeguard the health of the patient
Pharmacotherapy see pages 34 35 for coverage for prescription drugs

26 The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider When no PPO provider is available non PPO benefits apply 26
26 Page 27 28
Blue Cross and Blue Shield Service Benefit Plan 2000
Outpatient
surgery

Facility The Plan provides coverage at the benefit levels indicated below not subject to the calendar year
care deductible for the outpatient surgical services listed below when billed for by a facility
benefits High Option Standard Option

You pay nothing but the You pay nothing but the following copayments following copayments

PPO Preferred You pay 10 You pay 25 facilities
Member You pay 50 You pay 100 facilities
Non member You pay 100 You pay 150 facilities
These copayments will be applied per facility per day not per service You will be responsible for the lesser of the stated copayments or the Billed charge s If Preferred or Member facilities are
available and utilized you will be responsible for the lesser of the stated copayments the Billed charge s or the Preferred or Member rate at the time your claim is processed

Overseas care You pay nothing for outpatient surgical services at hospitals located outside the United States or Puerto Rico
Covered facility billed services are noted below
Surgical services and related other hospital services
Related X rays Magnetic Resonance Imagings MRIs laboratory and pathological services and machine diagnostic tests performed within one business day of the covered surgical

services Presurgical testing performed more than one business day prior to the surgery is covered as described on page 26 under Outpatient Facility Care Diagnostic services

Facility supplies for hemophilia home care
Physician care Except as noted the Plan provides coverage at the benefit levels indicated below for services provided or ordered and billed by a physician

High Option Standard Option
PPO Preferred After you pay the 150 calendar After you pay the 200 calendar physicians year deductible you pay 5 PPA year deductible you pay 10

PPA
Participating After you pay the 150 calendar After you pay the 200 calendar physicians year deductible you pay 20 year deductible you pay 25

PAR PAR
Non participating After you pay the 150 calendar After you pay the 200 calendar physicians year deductible you pay 20 year deductible you pay 25

NPA You are also responsible NPA You are also responsible for the difference between the for the difference between the
Plan's payment and the Plan's payment and the physician's actual charge physician's actual charge

See Definitions for an explanation of Preferred Participating and Non participating physicians and PPA PAR and NPA under Covered charges

Home and When you use Preferred physicians home and office visits physicians outpatient consultations and
office visits second surgical opinions are paid in full under High and Standard Options after a 12 copayment for each outpatient office visit charge These services are paid as described above when rendered by

Participating and Non participating physicians

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider 27 When no PPO provider is available non PPO benefits apply 27
27 Page 28 29
Blue Cross and Blue Shield Service Benefit Plan 2000
Diagnostic X rays Magnetic Resonance Imagings MRIs laboratory and pathological services and
services machine diagnostic tests including mammograms and Pap smears Certain diagnostic cancer tests are covered differently when provided by a Preferred provider see page 31

Laboratory and pathological services billed by an independent laboratory
Preventive The following routine screening procedures are paid as described above when performed by
services Participating and Non participating providers These services are covered differently when you use Preferred providers and the visit charge associated with these services is covered only with

Preferred providers see Additional Benefits page 31
The following schedules are applicable for Member and Non member facilities and Participating and Non participating providers

Breast Mammograms are covered for females age 35 and older as follows
cancer From age 35 through 39 one mammogram screening during this five year period
screening From age 40 through 64 one mammogram screening every calendar year

At age 65 or over one mammogram screening every two consecutive calendar years

Cervical cancer One Pap smear for females of any age every calendar year
screening

Colorectal cancer One fecal occult blood test for members age 40 and older every calendar year
screening One sigmoidoscopy for members age 50 and older every five years

Prostate cancer One PSA Prostate Specific Antigen test for males age 40 and older every calendar year
screening

Immunizations For influenza and pneumonia once every calendar year
Tetanus diphtheria Td booster once every ten calendar years
Lyme disease vaccine

Other Radiation therapy chemotherapy and renal dialysis chemotherapy and or radiation therapy
outpatient when supported by allogeneic or autologous bone marrow transplants or blood stem cell
services transplant support is covered only for those covered conditions as described under Organ tissue transplants and donor expenses under Surgical Benefits on pages 17 20

Physical occupational and speech therapy for visit limitations see page 30
Allergy tests surveys and injections blood as described on page 29 and prescription drugs
Hepatitis immunizations for patients with increased risk or family history
Under High Option physician home visits when receiving covered home health care see page 32

Covered services provided by a nurse midwife acting within the scope of licensure
Pharmacotherapy see pages 34 35 for coverage for prescription drugs

Other services Except as noted benefits for the following services are paid as follows
High Option Standard Option

After you pay the 150 calendar year After you pay the 200 calendar year deductible you pay 20 of the deductible you pay 25 of the

Allowable charge see Definitions Allowable charge see Definitions
Note Preferred and Participating providers may not be available for the following services in your area When they are available and utilized the Plan pays benefits as shown under Physician care
on page 27

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider
28 When no PPO provider is available non PPO benefits apply 28
28 Page 29 30
Blue Cross and Blue Shield Service Benefit Plan 2000
Ambulance Professional ambulance transport services
associated with covered hospital inpatient care
related to and within 72 hours after an accidental injury or medical emergency or
during covered home health care

Dental care for Services supplies or appliances for dental care to sound natural teeth see Definitions required as a
accidental injury result of and directly related to an accidental injury see Definitions

Durable medical Rental by the member or purchase at the Carrier's option if it will be less expensive of durable
equipment medical equipment such as respirators and home dialysis equipment including replacement repair and adjustment of purchased equipment

Wheelchairs hospital beds crutches and other items determined by the Carrier to be durable medical equipment

Home nursing Care by a registered nurse R N or licensed practical nurse L P N when the care is ordered by a
care physician Home nursing care is available for two 2 hours per day up to 50 visits per calendar year under High Option and 25 visits per calendar year under Standard Option The number of visits

for which you receive reimbursement will be reduced if these services are used to meet part or all of your calendar year deductible

Miscellaneous Allergy tests surveys and injections
services and Blood and blood plasma except when donated or replaced and blood plasma expanders
supplies Neurological testing when rendered and billed by a qualified clinical psychologist

One set of eyeglasses or contact lenses or one replacement to an existing prescription required as a result of and directly related to a single instance of intra ocular surgery or a single ocular

injury This benefit also applies when in situations as described above the condition can be corrected by surgery but surgery is precluded i e cannot be performed because of age or
medical complications and lenses are prescribed in lieu of surgery
Ostomy and catheter supplies
Oxygen regardless of the provider
Medical foods for children with inborn errors of amino acid metabolism
Prescription drugs not billed by a retail pharmacy excludes those drugs obtained through the Mail Service Prescription Drug Program

Home infusion therapy prescription drugs medical supplies durable medical equipment DME and home nursing visits subject to the calendar year visit limitations described above
under Home nursing care
Nonsurgical treatment for amblyopia and strabismus for children from birth through age 12
Functional foot orthotics when medically necessary and prescribed by a physician

Rigid devices attached to the foot or a brace or placed in a shoe
Acupuncture as a modality of physical therapy and for pain management when rendered and billed by a physician or licensed physical therapist

Orthopedic braces and prosthetic appliances such as artificial legs and pacemakers including replacement repair and adjustment
Diabetic education when billed by a covered provider

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider 29 When no PPO provider is available non PPO benefits apply 29
29 Page 30 31
Blue Cross and Blue Shield Service Benefit Plan 2000
Physical Physical occupational and speech therapy when rendered by a physical occupational or speech
occupational therapist who is licensed or meets the requirements of the Carrier by a physician rendered on an
and speech outpatient basis or by an outpatient facility When billed by a skilled nursing facility nursing home
therapy or extended care facility benefits will be paid as shown on page 27 for professional care according to the contracting status of the professional provider that actually performs the therapy The

following limits apply to outpatient care

Physical therapy 75 visits under High Option and 50 visits under Standard Option per person per calendar year

Occupational therapy speech therapy or a combination of both 25 visits under High and Standard Options per person per calendar year
The number of visits for which you receive reimbursement will be reduced if these services are used to meet part or all of your calendar year deductible

See page 16 for physical occupational and speech therapy provided by a physician on an inpatient basis See pages 26 28 for payment levels for outpatient physical occupational and speech therapy
provided by a physician or outpatient facility
Limited benefits Smoking cessation After satisfaction of the calendar year deductible under High and Standard Options the Plan will

benefit pay 100 of Billed charges up to a maximum payment of 100 for enrollment in one smoking cessation program per member per lifetime Services may be rendered by any covered provider or
by a smoking cessation clinic
See pages 34 35 Prescription Drug Benefits for coverage of smoking cessation drugs

What is not covered Exercise and bathroom equipment Lifts such as seat chair or van lifts
Air conditioners humidifiers dehumidifiers and purifiers Shoes and over the counter orthotics

Wigs Breast pumps
Implanted bone conduction hearing aids Computer story boards or light talkers for communication impaired individuals
Maintenance or palliative physical occupational or speech therapy for a chronic disease or condition which does not require the technical proficiency or the skill and training of a
physician or qualified physical occupational or speech therapist except during acute exacerbations of the disease or condition

Home nursing care when
1 Requested by or for the convenience of the patient or the patient's family or 2 It consists primarily of bathing feeding exercising homemaking moving the patient

giving medication or acting as a companion or sitter

30 The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider When no PPO provider is available non PPO benefits apply 30
30 Page 31 32
Blue Cross and Blue Shield Service Benefit Plan 2000
Additional Benefits
Preventive services The Plan provides coverage for each home and office visit for a routine physical examination at the benefit levels indicated below when provided by a Preferred physician or Preferred facility
provided by After you pay a 12 copayment you After you pay a 12 copayment you
Preferred providers pay nothing under High Option pay nothing under Standard Option

Routine physical Home and office visits for routine screening examination consisting of a history and risk
examination assessment chest X ray electrocardiogram EKG urinalysis basic metabolic or comprehensive metabolic panel test and complete blood count CBC are covered for members as follows

Through age 64 once every three consecutive calendar years
At age 65 or over once every calendar year

This benefit does not apply to children eligible for Well Child Care benefits
Additionally the preventive screening tests and immunizations noted below are paid in full when provided by a Preferred physician or a Preferred facility on an outpatient basis subject to the

schedules indicated If these services are rendered by a Preferred physician separately from the routine physical examination you will be responsible for the 12 copayment for each associated
office visit
Coronary artery Cholesterol tests are covered for members as follows
disease screening Through age 64 once every three consecutive calendar years
At age 65 or over once every calendar year

This benefit does not apply to children eligible for Well Child Care benefits
Preventive screening cholesterol tests are only covered and paid in full when provided by Preferred providers or any independent laboratory

Immunizations For influenza and pneumonia once every calendar year Tetanus diphtheria Td booster once every ten calendar years
Lyme disease vaccine
See pages 26 28 Other Medical Benefits for benefits for these immunizations provided by Member and Non member facilities and Participating and Non participating providers The visit charge

associated with these services is covered only with Preferred facilities or Preferred providers
Cancer tests The following diagnostic and screening cancer tests are paid in full when provided by a Preferred
diagnostic screening facility or a Preferred professional provider on an outpatient basis You are responsible for the 12 copay for each associated office visit
provided by Mammogram
Preferred providers Pap smear Fecal occult blood test

Sigmoidoscopy
PSA Prostate Specific Antigen test

See pages 26 28 Other Medical Benefits for payment levels and applicable schedules for these diagnostic and preventive services provided by Member and Non member facilities and Participating

and Non participating physicians The visit charge associated with these services is covered only with Preferred facilities or Preferred providers

Well child care For children up to age 22 you pay nothing under High and Standard Options for Covered charges for the following covered routine services for well child care
All healthy newborn inpatient physician visits including routine screening inpatient or outpatient

Routine physical examinations laboratory tests immunizations and related office visits including those for children living traveling or adopted from outside the United States as
recommended by the American Academy of Pediatrics

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider When no PPO provider is available non PPO benefits apply
31 31
31 Page 32 33
Blue Cross and Blue Shield Service Benefit Plan 2000
Accidental injury You pay nothing under High and Standard Options for Covered charges for the following covered services and supplies in connection with and within 72 hours after accidental injury see
outpatient care Definitions
Other hospital services in Preferred Member and Non member hospitals including related X rays Magnetic Resonance Imagings MRIs laboratory and pathological services and

machine diagnostic tests
Physician services in the office or hospital outpatient department including X rays Magnetic Resonance Imagings MRIs laboratory and pathological services and machine diagnostic tests

See Definitions for an explanation of Preferred Participating and Non participating physicians and Covered charges

Related benefits The following related services are covered under Other Medical Benefits see pages 26 30
Services related to accidental injury rendered more than 72 hours after the injury
Care for accidental dental injury
Ambulance transport services

Home health care
High Option You pay nothing under High Option for the covered home health care services listed below for up to 90 days per calendar year if

1 the services rendered are billed by a home health care agency such as the hospital or a visiting nurse association that has a written agreement with the Local Plan to provide home health care
services and
2 prior approval is obtained from the Local Plan If prior approval is not obtained Other Medical Benefits will be provided as applicable

Note The member has the responsibility to make sure that the home health care provider has received prior approval from the Local Plan see pages 48 49 for instructions Please check with
your Local Plan and or your PPO directory for listings

What is covered Nursing care such as dressing changes injections and monitoring of vital signs Physical therapy
Respiratory or inhalation therapy
Prescription drugs
Medical supplies which serve a specific therapeutic or diagnostic purpose
Infusion therapy
Other medically necessary services or supplies that would have been provided by a hospital if the member was hospitalized

See page 28 for High Option coverage for physician home visits while receiving covered home health care services

What is not covered Home health care services related to the treatment of mental conditions substance abuse for routine maternity care for routine monitoring of a condition for intermittent care of a stable
condition or for initial evaluation of the patient to determine whether or not home health care is appropriate

Homemaking services including housekeeping preparing meals or acting as a companion or sitter

Standard Option See page 29 for Standard Option coverage of home nursing care

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider
32 When no PPO provider is available non PPO benefits apply 32
32 Page 33 34
Blue Cross and Blue Shield Service Benefit Plan 2000
Home hospice care You pay nothing under High and Standard Options if prior approval is obtained from the Local Plan for covered home hospice services rendered to members with a life expectancy of six months or
less when billed by a home hospice care agency which is approved by the Local Plan
Note You are responsible to make sure that the home hospice care provider has received prior approval from the Local Plan see page 48 for instructions Please check with your Local Plan

and or your PPO directory for listings

What is covered Physician visits Services of home health aides Nursing care Durable medical equipment rental
Medical social services Prescription drugs Physical therapy Medical supplies

Related inpatient Inpatient hospice benefits are available only to a member receiving Home hospice care benefits
services Benefits are provided for up to five 5 consecutive days in a hospital or a freestanding hospice inpatient facility These covered inpatient hospice benefits are available only when inpatient
services are necessary to control pain and manage the symptoms of the patient or to provide an interval of relief to the family respite

Each inpatient stay must be separated by at least 21 days You pay nothing under High and Standard Options when you are admitted to a Preferred hospital If you are admitted to a Member
or Non member hospital you pay 100 per admission deductible under High Option and you pay a 250 per admission deductible under Standard Option See page 15 for Inpatient Hospital
Benefits

What is not covered Homemaker or bereavement services
Limited benefits

Skilled nursing When Medicare Part A is primary payer it pays first and has made payment High and Standard
facilities Options provide secondary benefits for the applicable Medicare Part A copayments incurred in full during the first through the 30th day of confinement for each benefit period as defined by Medicare

in a qualified skilled nursing facility see page 9 If Medicare pays the first 20 days in full Plan benefits will begin on the 21st day when Medicare Part A copayments begin and will end on the

30th day
24 Hour nurse Help with health concerns is available 24 hours a day 365 days a year by calling a toll free
telephone service telephone number 1 888 258 3432 or accessing an Internet web site www Bluehealth org The service called Blue Health Connection features health advice or health information and counseling

by registered nurses Also available is the AudioHealth Library with hundreds of tapes ranging from first aid to infectious diseases to general health issues You can get information about health

care resources to help you find local doctors hospitals or other health care services affiliated with the Blue Cross and Blue Shield Service Benefit Plan This service is offered in certain pilot areas
and will become available in additional areas during 2000 Contact us at the number above or visit our web site for more information

We will send a membership kit and other information about Blue Health Connection in the mail to enrollees who live in the states where this service is available

Patient support The Service Benefit Plan is developing and may offer patient support programs for certain diagnoses
programs in select locations on a pilot basis

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider 33 When no PPO provider is available non PPO benefits apply 33
33 Page 34 35
Blue Cross and Blue Shield Service Benefit Plan 2000
Prescription Drug Benefits
What is covered You may purchase up to a 90 day supply of the following medications and supplies prescribed by a doctor from either a pharmacy or by mail however quantities may be limited for certain drugs such
as narcotics
Drugs vitamins and minerals and nutritional supplements that by Federal law of the United States require a doctor's prescription for their purchase

Insulin Needles and disposable syringes for the administration of covered medications
Intrauterine devices IUDs Norplant Depo Provera diaphragms and oral contraceptives dispensed by a retail pharmacy and oral contraceptives obtained through the Mail Service
Prescription Drug Program
Drugs to aid smoking cessation that require a prescription by Federal law limited to one regimen per calendar year

In most cases refills cannot be obtained until 75 of the drug has been used Call the Retail Pharmacy Program 1 800 624 5060 TDD 1 800 624 5077 or the Mail Service Prescription Drug
Program 1 800 262 7890 TDD 1 800 446 7292 for exceptions to this policy Not all drugs are available through the Mail Service Program

You can save money by using generic drugs By submitting your prescription or those of family members covered by the Plan to your retail pharmacy or the Mail Service Prescription Drug
Program you authorize them to substitute a Federally approved generic equivalent if available unless you or your physician specifically requests a name brand

What is not covered Medical supplies such as dressings and antiseptics Drugs and supplies for cosmetic purposes
Medication that does not require a prescription under Federal law even if your doctor prescribes it or a prescription is required under your State law

Drugs prescribed for weight loss Drugs for orthodontic care dental implants and periodontal disease
Drugs for which prior approval has been denied

From a pharmacy You may purchase up to a 90 day supply of covered drugs and supplies through the Retail Pharmacy Program Call 1 800 624 5060 TDD 1 800 624 5077 to locate a Preferred pharmacy in your area
High Option Standard Option
PPO Preferred You pay 15 PPA You pay 25 PPA retail pharmacies

Non preferred retail You pay 35 AWP You are You pay 45 AWP You are pharmacies also responsible for the also responsible for the
difference between the Plan's difference between the Plan's payment and the pharmacy's payment and the pharmacy's
actual charge actual charge
You must present your Plan ID card at the time of purchase at a Preferred pharmacy You are only responsible for the applicable coinsurance at the time of purchase All Preferred retail pharmacies
will file claims for you Preferred pharmacies will receive the payment and agree to accept 100 of the PPA as payment in full At Non preferred retail pharmacies you must pay the full cost at the
time of purchase and submit a claim You are responsible for the applicable coinsurance based upon the Average Wholesale Price AWP and any amounts in excess of the allowance Certain
prescription drugs and supplies may require prior approval see pages 35 and 48 49 Any savings received by the Carrier on the cost of drugs purchased under this Plan from drug manufacturers are
credited to the reserves held for this Plan

34 The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider When no PPO provider is available non PPO benefits apply 34
34 Page 35 36
Blue Cross and Blue Shield Service Benefit Plan 2000
To claim benefits Use a retail prescription drug claim form for prescription drugs and supplies purchased at Nonpreferred retail pharmacies You may obtain these forms by calling 1 800 624 5060 TDD
1 800 624 5077 Follow the instructions on the form and mail it to the Blue Cross and Blue Shield Service Benefit Plan Retail Pharmacy Program P O Box 52057 Phoenix AZ 85072 2057

By mail If your doctor orders more than a 21 day supply of covered drugs or supplies up to a 90 day supply you may order your prescription or refill by mail from the Mail Service Prescription Drug Program
Merck Medco Rx Services will fill your prescription
You pay an 8 generic and 14 brand name copayment under High Option and a 12 generic and 20 brand name copayment under Standard Option for each prescription drug supply or refill you

purchase through the Mail Service Prescription Drug Program
To claim benefits The Plan will send you information on the Mail Service Prescription Drug Program To use the Program
1 Complete the initial mail order form 2 Enclose your prescription and copayment

3 Mail your order to Merck Medco Rx Services P O Box 30492 Tampa FL 33633 0144 4 Allow approximately two weeks for delivery

Alternatively your physician may call in your initial prescription at 1 800 262 7890 TDD 1 800 446 7292 You will be billed later for the copayment After that to order your refill you
may either call the same number or access this Plan's website at http www fepblue org and either charge your copayment to your credit card or have it billed to you later You should allow
approximately one week for delivery
Prior approval Certain prescription drugs and supplies may require prior approval before they will be covered under this Plan and prior approval must be renewed periodically Call 1 800 624 5060 TDD
1 800 624 5077 to obtain an updated list of prescription drugs and supplies that require prior approval Once prior approval has been obtained or renewed you may take advantage of electronic

claims processing at Preferred pharmacies have claims paid for drugs and supplies purchased from Non preferred pharmacies or have drugs and supplies dispensed by the Mail Service Prescription
Drug Program
Retail Pharmacy The Retail Pharmacy Program will request the medical evidence needed to make its coverage
Program determination Drugs and supplies that require prior approval also require 1 payment in full at time of purchase including Preferred pharmacies and 2 the member's submission of the expense s on a

claim form Preferred pharmacies will not file these expenses for you

Mail Service Merck Medco Rx Services will screen all prescription drugs prior to dispensing If the drug or
Program supply requires prior approval your prescription will not be filled until prior approval has been obtained The prescription will be returned to you along with a Prior Approval Request form and a

letter explaining the program and procedures

Drugs from other Prescription drugs and certain supplies not purchased from a retail pharmacy or through the Mail Service Prescription Drug Program are covered at Other Medical Benefits levels when billed for by
sources an outpatient facility or a physician see pages 26 28 or Additional Benefits levels when billed for by a covered home health care agency see page 32 or home hospice agency see page 33 When

hospitalized drugs and supplies are covered under Inpatient Hospital Benefits see page 15 or Maternity Benefits see page 22

Purchasing drugs Claims for covered prescription drugs and supplies purchased outside of the United States and
when you are Puerto Rico should be submitted on an Overseas Claim Form and sent to the Overseas Claims Section address listed on page 40 These drugs must be equivalent to drugs that by Federal law of
overseas the United States require a prescription Prescription drugs requiring constant refrigeration cannot be shipped to APO FPO boxes by the Mail

Service Prescription Drug Program
Coordinating with When you use a Preferred retail pharmacy and this Plan is the primary payer you must call the Blue Cross and Blue Shield Service Benefit Plan Retail Pharmacy Program at 1 800 624 5060 TDD
other drug coverage 1 800 624 5077 to request a statement of benefits for other coverage purposes

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider 35 When no PPO provider is available non PPO benefits apply 35
35 Page 36 37
Blue Cross and Blue Shield Service Benefit Plan 2000
Standard Option Dental Benefits
What is covered The Plan will pay Billed charges for the following services up to the amount specified in the Schedule of Dental Allowances below This is a complete list of covered dental benefits for
Standard Option These benefits are not available under High Option

Preferred Dental The PPO now includes Preferred dentists who are available in all Local Plans in most areas
Network Preferred dentists agree to accept a negotiated discount amount called the Maximum Allowable Charge MAC as payment in full for the services listed below These dentists may not be Preferred

for other services covered by this Plan under other benefit provisions such as oral and maxillofacial surgery or Other Medical Benefits They will also file your dental claims for you You are

responsible as an out of pocket expense for the difference between the amount specified on this Schedule of Dental Allowances and the MAC To find a Preferred dentist near you or to obtain a
copy of the MAC listing applicable to your area contact your Local Plan
Complete schedule of ADA Up to Age 13
dental allowances Code Age 13 and over

Clinical oral 0120 Periodic oral evaluation 12 8
evaluations 0140 Limited oral evaluation 14 9 0150 Comprehensive oral evaluation 14 9

0160 Detailed and extensive oral evaluation 14 9

Radiographs 0210 Intraoral complete series 36 22 0220 Intraoral periapical first film 7 5
0230 Intraoral periapical each additional film 4 3 0240 Intraoral occlusal film 12 7

0250 Extraoral first film 16 10 0260 Extraoral each additional film 6 4
0270 Bitewing single film 9 6 0272 Bitewings two films 14 9
0274 Bitewings four films 19 12 0277 Bitewings vertical 12 7
0290 Posterior anterior or lateral skull and facial bone survey film 45 28
0330 Panoramic film 36 23

Tests and laboratory 0460 Pulp vitality tests 11 7
exams

Palliative treatment 9110 Palliative emergency treatment of dental pain minor procedure 24 15
2940 Sedative filling 24 15

Preventive 1120 Prophylaxis child 22 14 1110 Prophylaxis adult 16
1201 Topical application of fluoride including prophylaxis child 35 22

1203 Topical application of fluoride prophylaxis not included child 13 8
1205 Topical application of fluoride including prophylaxis adult 24
1204 Topical application of fluoride prophylaxis not included adult 8

Space maintenance 1510 Space maintainer fixed unilateral 94 59
passive appliances 1515 Space maintainer fixed bilateral 139 87 1520 Space maintainer removable unilateral 94 59

1525 Space maintainer removable bilateral 139 87 1550 Recementation of space maintainer 22 14

Limited to two per person per calendar year

36 36
36 Page 37 38
Blue Cross and Blue Shield Service Benefit Plan 2000
ADA Up to Age 13 Code Age 13 and over
Amalgam 2110 Amalgam one surface primary 22 14
restorations 2120 Amalgam two surfaces primary 31 20
including 2130 Amalgam three surfaces primary 40 25
polishing 2131 Amalgam four or more surfaces primary 49 31 2140 Amalgam one surface permanent 25 16
2150 Amalgam two surfaces permanent 37 23 2160 Amalgam three surfaces permanent 50 31

2161 Amalgam four or more surfaces permanent 56 35

Filled or unfilled 2330 Resin one surface anterior 25 16
resin restorations 2331 Resin two surfaces anterior 37 23 2332 Resin three surfaces anterior 50 31

2335 Resin four or more surfaces or involving incisal angle anterior 56 35

2380 Resin one surface posterior primary 22 14 2381 Resin two surfaces posterior primary 31 20
2382 Resin three or more surfaces posterior primary 40 25 2385 Resin one surface posterior permanent 25 16
2386 Resin two surfaces posterior permanent 37 23 2387 Resin three surfaces posterior permanent 50 31
2388 Resin four or more surfaces posterior permanent 50 31

Inlay restorations 2510 Inlay metallic one surface 25 16 2520 Inlay metallic two surfaces 37 23
2530 Inlay metallic three or more surfaces 50 31 2610 Inlay porcelain ceramic one surface 25 16

2620 Inlay porcelain ceramic two surfaces 37 23 2630 Inlay porcelain ceramic three or more surfaces 50 31
2650 Inlay composite resin one surface 25 16 2651 Inlay composite resin two surfaces 37 23
2652 Inlay composite resin three or more surfaces 50 31

Other restorative 2951 Pin retention per tooth in addition to restoration 13 8
services Extractions includes
7110 Single tooth 30 19
local anesthesia and 7120 Each additional tooth 27 17
routine post operative 7130 Root removal exposed roots 71 45
care

Surg