Pages 1--52 from RI 71-013

Who may enroll in this Plan All Federal employees and annuitants who are eligible to enroll in the Federal Employees Health Benefits Program and who are or become members or League
Benefit Members of the National League of Postmasters of the United States
To become a member or League Benefit Member To be eligible for membership in the League you must be an active or retired employee of the Federal government or the United
States Postal Service
Annuitants retirees may enroll in this Plan
Membership dues New League Benefit Members will be billed separately 35 for annual dues when the Plan receives notice of enrollment Continuing members will be billed by the League
for the annual membership dues
Postmaster members must pay dues based on level of office Dues are paid by payroll deduction or annually at the option of the Postmaster Continuing Postmaster members are billed annually
for membership dues

Enrollment code for this Plan
HIGH OPTION STANDARD OPTION 361 Self only 364 Self only

362 Self and family 365 Self and family

Visit the OPM website at http www opm gov insure and
Our website at http www postmasters org pbp asp

Authorized for distribution by the
UNITED STATES OFFICE OF
PERSONNEL MANAGEMENT
RI 71 013 1
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Postmasters 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 5 10
Section 4 What to do if we deny your claim 11 12
Section 5 Benefits 13 29
Section 6 How to file a claim 30 31
Section 7 General exclusions Things we don't cover 32
Section 8 Limitations Rules that affect your benefits 33 37
Section 9 Fee for Service Facts 38 41
Section 10 FEHB facts 42 45
Department of Defense FEHB Demonstration Project 45 46
Inspector General Advisory Stop Healthcare Fraud 47
Index 49
Summary of benefits Inside back cover

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Postmasters Benefit Plan 2000
Introduction
Postmasters Benefit Plan 1019 North Royal Street Alexandria Virginia 22314 1596
This brochure describes the benefits you can receive from the Postmasters Benefit Plan sponsored by the National League of Postmasters under its contract CS 1071 with the Office of Personnel Management OPM as authorized by the Federal
Employees Health Benefits FEHB law This Plan is underwritten by the National League of Postmasters with reinsurance from the Lexington Insurance Company

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 page 4 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 Postmasters 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 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 Plan 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 to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not to pay for your claim or a portion of your claim

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 definition section

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

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Postmasters 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 varies 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 through a company called First Health Group Corp which provides a PPO known as the First Health Medical
Network This arrangement with health care providers gives you enhanced benefit payments or limits your out of pocket expenses when you receive care from a PPO provider

Section 2 How we change for 2000
Do not rely on this page It is not an official statement of benefits
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary changes care office visits that are subject to a copay

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 specialist is leaving our PPO network at our request without cause we will notify you
You may continue to receive our PPO level 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 to review or obtain 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 will cover a screening sigmoidoscopy every five years This screening is for colorectal cancer

Changes to this Plan
Both Options The catastrophic protection provision no longer applies to prescription drug coverage
Our PPO payment level for outpatient hospital services and professional services is reduced from 95 to 90

High Option The calendar year deductible for prescriptions filled at a participating pharmacy is reduced from 100 to 50 and the 20 paid by the patient is reduced to a 5 copayment for generic
drugs and a 12 copayment for brand name drugs We continue to pay the balance in full The benefit for prescriptions filled at a non participating pharmacy is not changed

Your share of the High Option PBP premium will increase by 5.5 for Self Only or 5.2 for Self and Family
For Postal Premium A employees your share of the High Option PBP premium will increase by 4.9 for Self Only or 1.8 for Self and Family
For Postal Premium B employees your share of the High Option PBP premium will increase by 4.7 for Self Only or 4.8 for Self and Family

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Postmasters Benefit Plan 2000
Section 2 How we change for 2000 continued
Standard Option The deductible for admission to a Non PPO hospital is reduced from 600 to 250
The 350 deductible for admission to a PPO hospital is eliminated
The calendar year covered expenses which the enrollee must pay out of pocket before receiving Non PPO benefits at the 100 level under the Catastrophic Protection provision is

reduced from 6,700 to 4,500
Our payment rate for covered hospital services rendered by a PPO hospital increases from 95 to 100

The PPO office visit copayment is decreased from 20 to 10 and now includes x rays labs and surgeries rendered during the visit
The Point of Service POS program is eliminated Non PPO and PPO benefits remain
Your share of the Standard Option PBP premium will increase by 4.2 for Self Only or 3.4 for Self and Family

For Postal Premium A employees your share of the Standard Option PBP premium will increase by 1.6 for Self Only or decrease -9.5 for Self and Family
For Postal Premium B employees your share of the Standard Option PBP premium will increase by 0.9 for Self Only or increase 1.2 for Self and Family

Section 3 How to get benefits
How do I keep my health care
expenses down
You can help FEHB Plans are expected to manage their costs prudently All FEHB Plans have cost containment measures in place All fee for service Plans include two specific provisions in their

benefits packages precertification of all inpatient admissions and the flexible benefits option Some include managed care options such as PPO's to help contain cost

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 You or your doctor must check with First Health Group Corp 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 page
38 of this brochure
Flexible benefits Under the flexible benefits option we have the authority to determine the most effective way to option provide services We 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 We may decide to resume regular contract benefits at our 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 ours and may be withdrawn at any time It is
not subject to OPM review under the disputed claims process
PPO We offer most of our members the opportunity to reduce out of pocket expenses by choosing providers who participate in our preferred provider organization PPO Consider the PPO cost
savings when you review Plan benefits and check with First Health Group Corp to see whether PPO providers are available in your area

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Postmasters Benefit Plan 2000
Section 3 How to get benefits continued
How much do I pay You must share the cost of some services These cost sharing measures include deductibles for services coinsurance and copayments These measures are described in more detail below

The copayments for Mail Order Prescription Drugs are waived under both options when Medicare Part B is the primary payer see page 24
The coinsurance may be waived when Medicare is primary see page 34
The coinsurance is not applied after the Catastrophic out of pocket expense limit is met see page 39

Deductibles A deductible is the amount of expense an individual 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 an individual must incur for covered services and supplies each calendar year before the Plan pays certain benefits The deductible is
200 PPO or 275 Non PPO for the High Option and 200 PPO or 350 Non PPO for the Standard Option Under High Option only charges for services covered under Other Medical
Benefits would apply to this deductible Under Standard Option only charges for services covered under Surgical Benefits and Other Medical Benefits would apply to this deductible Standard
Option is subject to a separate deductible for mental condition inpatient hospital visits and outpatient care

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
Drug Under High Option there is a 100 calendar year drug deductible for non participating pharmacies a 50 calendar year drug deductible for participating pharmacies and no deductible
for the Mail Order Drug program Under Standard Option there is a 100 calendar year drug deductible for non participating pharmacies and a 50 calendar year drug deductible that applies
to participating pharmacies and the Mail Order Drug Program See pages 23 24 for waivers that apply to Medicare Part B enrollees

Hospital The per person admission deductible does not apply for admissions to PPO hospitals for either High Option or Standard Option The per admission deductible for Inpatient Hospital Benefits
when using a non PPO hospital is 150 for the High Option and 250 for the Standard Option see page 13 The High Option and Standard Option deductible for mental conditions is 500
per admission The High Option and Standard Option deductible for substance abuse is 500 per person per year

Dental The High Option deductible for Basic and Major Dental Benefits is 30 per person per calendar year There is no Standard Option deductible for Dental Benefits
Carryover If you changed to this Plan during open season from a Plan with a deductible and the effective date of the change was after January 1 any expenses that would have applied to that Plan's
deductible in the prior year will be covered by your old Plan if they are for care you received in January before the effective date of your coverage in this Plan If you have already met the
deductible in full your old Plan will reimburse these covered expenses If you have not met it in full your old Plan will first apply your covered expenses to satisfy the rest of the deductible and
then reimburse you for any additional covered expenses The old Plan will pay these covered expenses according to this year's benefits benefit changes are effective on January 1

Family limit There is a separate calendar year deductible of 200 PPO or 275 Non PPO per person under the High Option and 200 PPO or 350 Non PPO per person under the 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 deductible for all family
members reach 400 PPO or 550 Non PPO under High Option and 400 PPO or 700 Non PPO under Standard Option during a calendar year If two or more persons under the
same family enrollment are injured in the same accident only one deductible need be satisfied that calendar year by those injured

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Postmasters Benefit Plan 2000
Section 3 How to get benefits continued
Coinsurance Coinsurance is the stated percentage of covered charges you must pay after you have met any
applicable deductible The Plan will base this percentage on either the billed charge or the reasonable and customary charge whichever is less For instance when a Plan pays 80 of

reasonable and customary charges for a covered service you are responsible for 20 of the reasonable and customary charges i e the coinsurance In addition you may be responsible for
any excess charge over the Plan's reasonable and customary allowance For example if the provider ordinarily charges 100 for a service but the Plan's reasonable and customary allowance
is 95 the Plan will pay 80 of the allowance 76 You must pay the 20 coinsurance 19 plus the difference between the actual charge and the reasonable and customary allowance 5
for a total member responsibility of 24 Remember if you use preferred providers your share of covered charges after meeting any deductible is limited to the stated coinsurance amount

When hospital When inpatient claims are paid according to a Diagnostic Related Group DRG limit for charges are limited instance for admissions of certain retirees who do not have Medicare see page 37 the Plan
by law will consider 30 of the total covered amount as room and board charges and 70 as other charges and will apply your coinsurance accordingly

Copayments A copayment is the stated amount the Plan requires you to pay for a covered service such as 10 per prescription by mail or 10 per office visit charge at a PPO provider
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 20 coinsurance
the actual charge is 80 The Plan will pay 64 80 of the actual charge of 80
Lifetime maximums Both Options The Plan will pay up to 100 for enrollment in one smoking cessation program per member per lifetime

Do I have to You usually do not have to submit claims to us if you use preferred providers If you file a submit claims claim please send us all of the documents for your claim You must submit claims by 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 Free standing An out of hospital facility such as medical cancer dialysis or surgical center or clinic and
ambulatory licensed outpatient facilities accredited by the Joint Commission on Accreditation of Healthcare
facility Organizations for treatment of substance abuse

Hospice A facility whose staff must include a doctor and registered nurse R N and may include social
workers clergymen counselors volunteers clinical psychologists and physical or occupational therapists who are able to provide care 24 hours a day

Hospital l An institution that is accredited as a hospital under the hospital accreditation program of the
Joint Commission on Accreditation of Healthcare Organizations or

2 Any other institution that is operated pursuant to law under the supervision of a staff of doctors with 24 hour a day nursing service and that is primarily engaged in providing for

sick and injured inpatients general care and treatment through medical diagnostic and major surgical facilities all of which facilities must be provided on its premises or under its
control or specialized care and treatment through medical and diagnostic facilities including X ray and laboratory on its premises under its control or through a written agreement with
a hospital as defined above or with a specialized provider of those services
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Postmasters Benefit Plan 2000
Section 3 How to get benefits continued
Rehabilitation An institution that 1 meets the hospital definition as stated or 2 provides a program for the
Facility treatment of alcohol or drug abuse and meets one of the following requirements a is affiliated with a hospital under a contractual agreement with an established patient referral system b is

licensed certified or approved as an alcohol or drug abuse rehabilitation facility by the State or is accredited as such a facility by the Joint Commission on Accreditation of Healthcare
Organizations
Skilled nursing An institution that 1 is operated pursuant to law and primarily engaged in providing the
facility following services for patients recovering from an illness or injury room board and 24 hour a
day nursing service by professional nurses 2 is under the fulltime supervision of a doctor or registered nurse R N 3 maintains adequate medical records and 4 has the services of a

doctor available under an established agreement for 24 hours a day if not supervised by a doctor
Covered providers For purposes of this Plan covered providers include
A licensed doctor of medicine M D or a licensed doctor of osteopathy D O Other covered providers include a licensed doctor of podiatry D P M a licensed dentist D D S or D M D

licensed chiropractor D C licensed or registered physical occupational and speech therapists R P T R S T R O T and S P practicing within the scope of their license Other covered
providers include a qualified clinical psychologist clinical social worker optometrist nurse midwife Certified Registered Nurse Anesthetist C R N A nurse practitioner clinical specialist
and nursing school administered clinic For purposes of this FEHB brochure the term doctor includes all of these providers when the services are performed within the scope of their license
or certification
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
underserved areas For 2000 the States designated as medically underserved are Alabama Idaho Kentucky
Louisiana Mississippi Missouri New Mexico North Dakota South Carolina South Dakota Utah and Wyoming

PPO arrangements Benefits under this Plan are available from facilities such as hospitals and from providers such
as doctors and other health care personnel who provide covered services This Plan covers two types of facilities and providers 1 those who participate in a preferred provider organization

PPO and 2 those who do not Who these health care providers are and how benefits are paid for their services are explained below In general it works like this

PPO facilities and providers have agreed to provide most services to Plan members at a lower cost than you'd usually pay a non PPO provider Although PPO's are not available in all locations
or for all services when you use these providers you help contain health care costs and reduce what you pay out of pocket The selection of PPO providers is solely the Carrier's responsibility
continued participation of any specific provider cannot be guaranteed While PPO providers agree with the Carrier to provide covered services final decisions about health care are the sole
responsibility of the doctor and patient and are independent of the terms of the insurance contract
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

When you use a PPO hospital keep in mind that the professionals who provide services to you in the hospital such as radiologists anesthesiologists and pathologists may not all be preferred
providers If they are not they will be paid by this Plan as non PPO providers
Non PPO facilities and providers do not have special agreements with the Carrier The Plan makes its regular payments toward their bills and you're responsible for any balance

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Postmasters Benefit Plan 2000
Section 3 How to get benefits continued
This Plan's PPO The Plan provides a national network of Preferred Provider Organizations PPO through a company called First Health Group Corp This PPO network First Health Medical Network
offers hospitals and doctors in numerous geographic areas however the number or type of providers may be insufficient in some geographic areas Network providers have agreed to
provide services to Plan enrollees and their dependents at negotiated rates PPO benefits are available for inpatient and outpatient hospital services inpatient and outpatient services of
doctors surgical procedures and anesthesia The Carrier is solely responsible for the selection of PPO providers and any questions regarding PPO providers should be directed to the Plan The
continued participation of any specific PPO provider cannot be guaranteed The patient can confirm the current sufficiency or limitation of the PPO network in the area where they intend to
receive care by calling toll free the PPO InfoLine or by visiting our website at www postmasters org pbp asp The PPO InfoLine offers Plan members a toll free number 1 800
654 6530 to obtain up to date information on the current status of providers within the Network The PPO InfoLine operates 24 hours a day 7 days a week The Plan is not responsible for
benefits in excess of the non PPO level of benefits based on the patient not confirming the current sufficiency of PPO providers

If you need hospital services and a PPO hospital is available in your area you may choose between a PPO provider and a non PPO provider at the time of service The rates that have been
negotiated with the PPO Providers will result in savings to you through a higher level of benefit payment When a High Option or Standard Option enrollee uses one of the PPO hospitals
there is no per admission room and board deductible The Plan will also pay covered Other charges at 100 under High Option and Standard Option

In addition to savings on the PPO hospitals the Plan offers a PPO Doctors Network Participating providers will provide discounted charges The Plan will pay 90 of the discounted charges
after any deductibles
The enrollees identification card will identify the patient as a participant of the First Health Group Corp PPO network and will alert medical care providers that the enrollee participates in the

Preferred Provider network PPO If an enrollee elects to use a non PPO provider the Plan will provide its usual coverage as outlined in this brochure Note Some discounts can be obtained
from network providers even though PPO benefits may not apply see pages 18 19 20 and 21 for services not covered under PPO benefits When you phone for an appointment please remember
to verify that the physician is still a PPO provider
What do I do if I'm First call our customer service department at 703 683 5585 If you are new to the FEHB in the hospital when Program we will reimburse your covered expenses Expenses incurred prior to your effective date
I join the Plan are not 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 92nd day after you became a member of this Plan whichever happens first

These provisions only apply to the person who is hospitalized

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 my continue seeing your provider for up to 90 days after you receive notice that we are terminating
provider leaves the our contract with the provider unless the termination is for cause If you are in the second or Plan or this Plan third trimester of pregnancy you may be able to continue to see your OB GYN until the end of
leaves the Program your postpartum care
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 your second or third trimester Your new Plan will pay 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
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Postmasters Benefit Plan 2000
Section 3 How to get benefits continued
How do you decide Claims with no procedure codes or experimental procedure codes are reviewed by PBP's if a service is
Technical Advisory Dept to determine whether the procedure is or is not experimental or experimental or investigational Claims requiring a review by a physician or specialist are sent to First Health

investigational Group Corp for review by appropriate physicians and specialists who recommend whether the
services should or should not be considered experimental or investigational PBP is responsible for the final decision Enrollees who have a question about a specific service or supply may call

us Several things suggest that a service or supply may be experimental or investigational
If a product is not FDA approved it may be experimental or investigational
If a service or treatment is still in some stage of trials it is experimental or investigational
If a service or treatment is not normally used to treat your condition it may be experimental or investigational

If a provider requires that you sign a special release prior to receiving the care it may be experimental or investigational

The determination of what is experimental or investigational changes over time Services that were once experimental such as a heart transplant may not be experimental today Services do
not move from experimental to non experimental overnight They usually take time to be fully recognized as non experimental

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
defined 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 show 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 means 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 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

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Postmasters Benefit Plan 2000
Section 4 What to do if we deny your claim
What should I do Before you ask us to reconsider your claim you should first check with your provider or facility before filing a to be sure that the claim was filed correctly For instance did they use the correct procedure code
disputed claim for the services performed surgery laboratory test X ray office visit etc Have your 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 won't pay your claim or a portion of your claim you may ask us to reconsider our decision Your request to us must
1 Be in writing
2 Refer to specific brochure wording 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 or
3 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 You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal OPM to review a and we have maintained our denial in writing OPM will determine if we correctly applied the
denial terms of our contract when we denied your claim
What if you have If we expedite your review due to a serious medical condition and deny your request we will denied my claim and inform OPM so that they can give your claim expedited treatment too Alternatively you can call
my condition is OPM's health benefits Contract Division II at 202 606 3818 between 8 a m and 5 p m Serious serious or life or life threatening conditions are ones that may cause permanent loss of bodily functions or death
threatening if they are not treated as soon as possible
Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our time limits initial denial 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

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Postmasters Benefit Plan 2000
Section 4 What to do if we deny your claim
Who can make Those who have a legal right to file a disputed claim with OPM are the request
1 Anyone covered under the Plan
2 The estate of a person once covered under the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the covered person's representative They must send a copy of the person's specific written consent with

the review request

What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our upholds the Plan's decision your only recourse is to sue
denial 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

Where should I Send your request for review to Office of Personnel Management Office of Insurance Programs mail my disputed Contracts Division II P O Box 436 Washington DC 20044
claim to OPM
What laws apply if Federal law governs your lawsuit benefits and payment of benefits The Federal court will base I file a lawsuit its 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 as established at section 890.105 title 5 Code of Federal Regulations CFR As required by 890.107 title 5 CFR such a lawsuit must be brought against the Office of
Personnel Management in Federal Court

Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you the Privacy Act and 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

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Postmasters Benefit Plan 2000
Section 5 Benefits

Inpatient Hospital Benefits What is covered The Plan pays 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 page 38 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 and Puerto Rico For information on when Medicare is primary see page 34

Room and board The Plan pays the following for room and board except for mental conditions or substance abuse treatment for ward semiprivate or intensive care Special diets and general nursing care are
included
PPO benefit High Option Plan pays full charges no Standard Option Plan pays full charges no
deductible deductible

See page 9 for information on PPO hospitals
Non PPO benefit High Option After a 150 per admission Standard Option After a 250 per
deductible Plan pays full charges admission deductible Plan pays 70 of covered charges

If a private room is used both options will pay the average semiprivate rate charged by the hospital If the hospital has private rooms only the average semiprivate rate is determined on the
basis of the semiprivate charge of the most comparable hospital in the area or the billed charge whichever is less If the patient's isolation is required to prevent contagion of others the private
room charge will be covered
Other charges Hospital services and supplies including but not limited to use of operating treatment and recovery rooms Xrays and lab tests chemotherapy drugs and medicines for use in the hospital
and blood or blood plasma not donated or replaced
PPO benefit High Option Plan pays 100 of covered Standard Option Plan pays 100 of
charges covered charges

Non PPO High Option Plan pays 85 for the first Standard Option Plan pays 70 of
benefit 30 days then 100 of covered charges covered charges

Limited benefits Hospitalization The Plan pays Inpatient Hospital Benefits for covered room and board charges and covered
for dental work hospital services and supplies in connection with dental procedures only when a non dental
physical impairment exists that makes hospitalization necessary to safeguard the health of the patient

Weekend Benefits for hospital admissions on Friday or Saturday are limited to 1 a medical emergency
admissions 2 surgery performed within 24 hours of admission or 3 a childbirth related admission

Related benefits Preadmission Preadmission testing is covered under Other Medical Benefits page 19
testing
Professional Charges for professional services of a doctor or any other practitioner covered by this Plan even
charges though billed by a hospital as part of hospital services are covered only under Other Medical
Benefits page 19 except for inpatient pathology and radiology charges which are payable as described above under Other charges

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Postmasters Benefit Plan 2000
Section 5 Benefits continued
Take home items Drugs medical supplies appliances medical equipment and any other covered items billed by a
hospital to be used at home are covered only under Other Medical Benefits pages 19 21

What is not covered Personal comfort items such as telephone and television guest meals and beds barber and beauty services

Custodial care see definition page 40
Room and board when the medical services did not require the acute hospital inpatient setting but could have been provided safely on an outpatient basis or in facilities that are primarily

1 convalescent nursing homes hotels or homes for the aged whose primary purpose is to furnish custodial care 2 operated as schools or 3 places for drug addicts or alcoholics
except as provided for Substance abuse rehabilitation on page 19
Private duty nursing care while confined in a hospital
Surcharges made by hospitals

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

Surgical Benefits
What is covered The Plan pays for the following services

Hospital inpatient For covered surgical procedures and outpatient

PPO benefit Both Options The Plan pays 90 of the surgeon's negotiated rate after the 200 calendar year
deductible has been met for Standard Option

Non PPO benefit High Option The Plan pays 85 of the Standard Option After the 350 calendar
reasonable and customary allowance year deductible has been met the Plan pays 70 of the reasonable and customary

allowance
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 as follows

PPO benefit Both Options The Plan pays 90 of the surgeon's negotiated rate after a 200 calendar year
deductible has been met for Standard Option for the major procedure and no more than 50 of the surgeon's negotiated rate for all subsequent procedures

Non PPO benefit High Option The Plan pays 85 of the Standard Option After the 350 calendar
reasonable and customary allowance for the year deductible has been met the Plan pays first or major procedure and 50 of the 70 of the reasonable and customary

reasonable and customary allowance for the allowance for the first or major procedure and second or lesser procedure s 50 of the reasonable and customary
allowance for the second or lesser procedure s

Incidental Both Options When an incidental procedure e g incidental appendectomy lysis of adhesions procedures
excision of scar is performed through the same incision the reasonable and customary allowance will be that of the major procedure only

Assistant surgeon inpatient outpatient
PPO benefit High Option The Plan pays 20 of the Standard Option After the 200 calendar
negotiated rate year deductible has been met the Plan pays assistant surgeons fees up to 15 of the

negotiated rate

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Postmasters Benefit Plan 2000
Section 5 Benefits continued
Non PPO benefit High Option Assistant surgeons fees are Standard Option After the 350 calendar
payable up to 20 of the reasonable and year deductible has been met the Plan pays customary allowance for the surgery assistant surgeons fees up to 15 of the

reasonable and customary allowance for the surgery

Second opinion Second surgical opinions are covered under Other Medical Benefits voluntary
Pre surgical testing Laboratory tests pathology radiology and X rays related to surgery are paid as Other Medical Benefits see page 19
Anesthesia PPO benefit Both Options The Plan pays 90 of the negotiated rate after the 200 calendar year
deductible has been met for Standard Option
Non PPO benefit High Option The Plan pays 85 of the Standard Option After the 350 calendar
reasonable and customary allowance year deductible has been met the Plan pays 70 of the reasonable and customary

allowance
Organ tissue This benefit applies only if the recipient is covered by the Plan A recipient is a person insured by transplants and the Plan who undergoes a surgical procedure to receive a body organ tissue transplant A donor is
donor expenses a person who undergoes a surgical procedure for the purpose of donating a body organ s tissue for transplant surgery All reasonable and customary inpatient hospital and medical charges
incurred for a surgical transplant whether incurred by the recipient or donor will be considered expenses of the recipient and will be covered the same as for any other illness or injury Plan
approval is required on all related expenses prior to the surgery The charges for procurement of cadaver organs are also based on Plan approval

Both Options Transplant charges will be covered up to a 100,000 maximum per transplant
What is covered Cornea bone heart kidney liver pancreas heart lung single lung and double lung transplants
Bone marrow transplants and stem cell support as follows
Allogeneic bone marrow for acute leukemia advanced Hodgkin's lymphoma advanced nonHodgkins lymphoma advanced neuroblastoma children over age one aplastic anemia chronic

myelogenous leukemia infantile malignant osteopetrosis severe combined immunodeficiency thalassemia major and Wiskott Aldrich syndrome

Autologous bone marrow transplants autologous stem cell and peripheral stem cell support for the following conditions acute lymphocytic or nonlymphocytic leukemia advanced Hodgkins
lymphoma and advanced non Hodgkins lymphoma advanced neuroblastoma testicular mediastinal retroperitoneal and ovarian germ cell tumors breast cancer multiple myeloma
and epithelial ovarian cancer
Related medical and hospital expenses of the donor are covered when the recipient is covered by the Plan

The Plan provides a Managed Transplant System MTS Program If the member agrees to participate in this program then charges for most of the above procedures are covered up to a
maximum of 300,000 per transplant Included in this 300,000 maximum is a travel and lodging allowance of 8,000 for the recipient and one family member Routine aftercare provided by the
transplant center and its affiliated providers for one year after the transplant is also included The MTS Program covers the following transplants bone marrow heart kidney pancreas liver heart
lung single lung and double lung transplants

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Postmasters Benefit Plan 2000
Section 5 Benefits continued
What is not Donor screening tests for organ transplants except those performed for the actual donor when
covered the recipient is covered by the Plan

Services or supplies for or related to organ tissue transplants for any diagnosis not specifically listed as covered including chemotherapy and or radiation therapy when supported by

allogeneic or autologous bone marrow or stem cell transplants 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 non covered procedure

Islet of Langerhans artificial heart and other transplants not listed as covered
Allogeneic and autologous bone marrow and stem cell transplants for solid tumors except as noted above

Oral and The following procedures are covered as shown on page 14 maxillofacial
Reduction of fractures of the jaw or facial bones surgery
Surgical correction of cleft lip cleft palate or severe functional malocclusion
Removal of stones from salivary ducts
Excision of tori leukoplakia or malignancies
Excision of cysts and incision of abscesses not involving the teeth
Removal of impacted teeth

When multiple or bilateral oral maxillofacial surgical procedures that add time or complexity to patient care are performed during the same operative session the Plan pays the same benefits as

indicated under Multiple surgical procedures for the above listed procedures except that removal of impactions are paid at the reasonable and customary allowance for each procedure performed
Procedures that involve teeth or their supporting structures such as the periodontal membrane gingiva and alveolar bone are considered dental treatment rather than oral surgery For covered
dental treatment see pages 24 through 28
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

Benefits will be provided for 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
What is not covered Eye surgery such as radial keratotomy when the primary purpose is to correct myopia hyperopia or astigmatism eye exercises and orthoptics visual training

Cosmetic surgery and all related expenses except for the correction of congenital anomalies or repair following an accidental injury
Injections of silicone collagens and similar substances
All procedures associated with treatment of temporomandibular disorders
Assistant surgery services rendered by a non physician provider such as a Physician Assistant P A Certified Registered Nurse First Assistant C R N F A and Certified Surgical

Technologist C S T

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

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Postmasters Benefit Plan 2000
Section 5 Benefits continued

Maternity Benefits What is covered The Plan pays the same benefits for hospital surgery delivery laboratory tests and other
medical expenses as for illness or injury The mother at her option may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a caesarean delivery Inpatient stays will be
extended if medically necessary
Inpatient hospital Precertification The medical necessity of your hospital admission must be precertified for you to receive full Plan
benefits Unscheduled or emergency admissions not precertified must be reported within two business days following the day of admission even if you have been discharged Newborn
admissions that extend beyond the mother's discharge must be precertified If any of the above are not done the benefits payable will be reduced by 500 See page 38 for details

Room and board Plan pays room and board charges for ward semiprivate or intensive care
PPO benefit High Option Plan pays full charges no Standard Option Plan pays full charges no
deductible deductible

See page 9 for information on PPO hospitals

Non PPO benefit High Option After a 150 per admission Standard Option After a 250 per
deductible Plan pays full charges admission deductible Plan pays 70 of covered charges

Other charges
PPO benefit High Option Plan pays 100 of covered Standard Option Plan pays 100 of
charges covered charges

Non PPO benefit High Option The Plan pays 85 for the Standard Option The Plan pays 70 of
first 30 days then 100 of covered charges covered charges

Hospital bassinet and nursery charges for days on which both mother and child would normally be confined following delivery are considered hospital expenses of the mother not the child
When a newborn requires definitive treatment or evaluation for medical or surgical reasons during or after the mother's stay the newborn is considered a patient in his or her own right and
a separate per admission deductible applies Expenses of the newborn are payable only if the child is covered under a Self and Family enrollment

Stand by doctor charges will be covered only if medically necessary treatment is actually rendered to the child by the doctor

Outpatient care Facility charges for an outpatient delivery or delivery at a birthing center are covered as outpatient surgery under Other Medical Benefits
Obstetrical care
PPO benefit Both Options The Plan pays 90 of the negotiated rate after the 200 calendar year
deductible has been met for Standard Option

Non PPO benefit High Option The Plan pays 85 of the Standard Option After the 350 calendar
reasonable and customary allowance year deductible has been met the Plan pays 70 of the reasonable and customary

allowance

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Postmasters Benefit Plan 2000
Section 5 Benefits continued
Related benefits
Diagnosis and Covered under Other Medical Benefits subject to Plan approval See page 19
treatment of
infertility

Pregnancy risk Covered under Other Medical Benefits subject to Plan approval See page 19
management
program

Voluntary Covered under Surgical Benefits See page 14
sterilization

For whom Benefits are payable under Self Only enrollments and for family members covered under Self and Family enrollments

What is not covered Assisted Reproductive Technology ART procedures such as artificial insemination in vitro fertilization embryo transfer and Gamete Intrafallopian Transfer GIFT as well as services
and supplies related to ART procedures are not covered
Reversal of voluntary surgical sterilization and all related expenses

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

Mental Conditions Substance Abuse Benefits
What is covered PPO benefits do not apply to Mental Conditions Substance Abuse Benefits The Plan pays for the following services

Mental conditions
Inpatient care High Option After a 500 per admission Standard Option After a 500 per
deductible the Plan pays 70 of covered admission deductible the Plan pays 60 of charges for inpatient room and board and covered charges for inpatient room and board

other hospital charges for up to 100 days per and other hospital charges for up to 100 days calendar year per calendar year

Two admissions in the same year separated by 30 or fewer days are considered one admission and require one deductible

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 page 38 for details

Inpatient visits High Option After the 275 calendar year Standard Option After the 300 per
deductible doctors inpatient services are person 600 per family mental conditions payable at 80 of reasonable and customary calendar year deductible doctors inpatient

charges for services rendered during the 100 services are payable at 50 of reasonable days per calendar year of covered inpatient and customary charges for services rendered
care during the 100 days per calendar year of covered inpatient care

Hospital Day Both Options The Plan provides benefits for day treatment subject to the Plan's approval treatment limited to the Plan's inpatient benefits See Inpatient Care above Day treatment is also known
as transitional care or partial hospitalization

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Postmasters Benefit Plan 2000
Section 5 Benefits continued
Outpatient care High Option After the 275 calendar year Standard Option After the 300 mental
deductible the Plan pays 50 of reasonable conditions calendar year deductible the Plan and customary charges to a maximum Plan pays 50 of reasonable and customary

payment of 50 per visit for up to 25 visits charges to a maximum Plan payment of per calendar year for the treatment of mental 50 per visit for up to 25 visits per calendar
conditions year for the treatment of mental conditions
Visits used by the member in satisfying the deductible do not count toward the 25 visit limit
Substance abuse Both Options After satisfaction of a 500 calendar year deductible the Plan pays 70 up to
annual maximum of the remaining covered charges for room and board and other charges made by a hospital or rehabilitation facility for treatment of alcohol or drug abuse including outpatient

services and supplies
Benefits for the treatment of substance abuse are limited to a maximum Plan payment of 3,500 per person per calendar year

Precertification Precertification requirements described above apply to all admissions for treatment of substance
abuse

What is not covered Treatment of learning disabilities
Treatment related to marital discord
Personal comfort items such as telephone and television guest meals and beds barber and beauty services

Custodial care see page 40
Other Medical Benefits
What is covered

PPO benefit High Option After the 200 calendar year Standard Option After the 200 calendar
deductible has been met the Plan pays 90 year deductible has been met the Plan pays of negotiated rate for the services listed on 90 of negotiated rate for the services listed

this page on this page except for home and office visits After a 10 co payment per visit the
Plan pays 100 for home and office visits including medical care rendered by the
doctor during the visit
Non PPO benefit High Option After the 275 calendar year Standard Option After the 350 calendar
deductible has been met the Plan pays 80 year deductible has been met the Plan pays of reasonable and customary charges for the 70 of reasonable and customary charges

following for the following
Home office and hospital visits and other medical care including office visits and tests used to monitor pharmacotherapy for mental conditions

Hospital services outpatient services and supplies including those related to services covered under Dental Benefits
Anesthesia and its administration for non surgical procedures see page 15 for benefits in conjunction with surgery
Allergy treatment serum and injections
Blood transfusions including blood plasma and blood plasma expanders
Radiation therapy and chemotherapy
Home IV therapy
Diagnostic X ray and laboratory tests including electrocardiogram electroencephalogram radioisotope other machine testing and preadmission diagnostic testing

Diagnosis and treatment of infertility when approved by the Plan see page 18 for exclusions
Pregnancy risk management programs when approved by the Plan

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Postmasters Benefit Plan 2000
Section 5 Benefits continued
Renal Dialysis
Physical occupational and speech therapy when prescribed by a doctor and rendered by a qualified professional therapist is payable up to a total of 40 visits under High Option and 24

visits under Standard Option per calendar year Each type of therapy rendered is considered a separate visit Speech therapy is payable only if services are provided to restore speech when
functional loss of speech is due to disease illness or injury
Routine services In addition to coverage of diagnostic X ray laboratory and pathology services and machine diagnostic tests the following routine screening services are covered as preventive care

Physical exams Routine physicals including a complete history and workup are covered once every two years for members age 13 through 39 and once every year for those age 40 and above
What is not Physical exams for school sports employment or travel
covered

Breast cancer Mammograms are covered for women age 35 and older as follows screening
From age 35 through 39 one mammogram screening during this five year period
From age 40 through 49 one mammogram screening every one or two consecutive calendar years

From age 50 through 64 one mammogram screening every calendar year At age 65 or older one mammogram screening every two consecutive calendar years

Cervical cancer Annual coverage of one pap smear for women age 18 and older screening
Colorectal cancer Annual coverage of one fecal occult blood test for members age 40 and older screening
At age 50 and older one sigmoidoscopy every five years

Prostate cancer Annual coverage of one PSA Prostate Specific Antigen test for men age 40 and older screening

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

PPO benefits do not apply to Other services or Limited benefits
Other services Disposable needles and syringes
Oxygen and equipment for its administration
Local professional ambulance service associated with covered hospital inpatient care or when related to and within 72 hours after an accidental injury or medical emergency or during

covered home health care
Insulin and diabetic supplies such as needles syringes and test materials
Orthopedic braces and prosthetic appliances such as artificial limbs and eyes when ordered by a doctor including replacement when required by a change in the patient's condition and

expenses for repair and adjustment

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Postmasters Benefit Plan 2000
Section 5 Benefits continued

Limited benefits Nursing services and
Benefits are provided for private duty nursing care performed outside the hospital by a registered home health care nurse R N licensed practical nurse L P N or licensed vocational nurse L V N and for

part time or intermittent nursing care furnished during home visits by an R N L P N L V N and home health aides that are part of a home health care plan that starts within 36 hours after
discharge from a covered hospital confinement
A doctor must certify in writing as to the 1 length of time such care is needed 2 specific professional skills required by the patient and 3 medical necessity for the skilled service In

addition for benefits to be paid for home visits the doctor must certify that further inpatient care would be required if home health care were not given and the home health care plan must be
coordinated by the hospital and the covered services billed for by a health care provider organization such as a hospital or a home health care agency The Plan may request nursing
notes
Benefits for nursing services and home health care are limited to a maximum Plan payment of 10,000 per person per calendar year

What is not Nursing care primarily for custodial care see page 40 covered
Smoking cessation After satisfaction of the calendar year deductible the Plan will pay up to 100 for enrollment in benefit one smoking cessation program including any related prescription drugs per member per
lifetime Smoking cessation drugs and medications including nicotine patches are not available under any other Plan provisions Benefits will be paid directly to the enrollee upon submission of
a completed claim form and bill
Supplies The following supplies are covered under specific circumstances
Hearing aids including exams and adjustments to hearing devices if required to correct a hearing impairment caused by surgery or injury and obtained within 120 days thereof

One pair of eyeglasses or contact lenses including exams if required to correct impairment directly caused by accidental ocular injury or intraocular surgery such as removal of
cataracts and obtained within one year of the injury or surgery
What is not Eyeglasses contact lenses including their replacements and spares special tinting and covered related examinations and tests except as provided above

Eye exercises and orthoptics visual training
Sun or heat lamps heating pads air conditioners purifiers and humidifiers exercise safety computer communication and convenience equipment stair glides ramps liftchairs elevators

and other modifications or alterations to vehicles or households whirlpools saunas and similar household items

Travel transportation convalescent care or rest cures
Orthopedic and corrective shoes arch supports foot orthotics and other supportive foot devices elastic stockings and support hose

Hearing aids and related examinations and tests except as provided above batteries glasses or ocular exams if part of hearing device repairs or replacements of hearing devices
Services and supplies for cosmetic purposes such as Rogaine or wigs
Chelation therapy except for acute arsenic gold lead or mercury poisoning
Maintenance cardiac rehabilitation and exercise programs

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Postmasters Benefit Plan 2000
Section 5 Benefits continued

Additional Benefits Accidental injury Both Options pay 100 of reasonable and customary charges for non surgical outpatient
treatment rendered within 72 hours of an accidental injury see page 40
Chiropractic services Chiropractic treatment is payable for up to 15 per visit under High Option not to exceed 25 visits per calendar year and up to 10 per visit under Standard Option not to exceed 12 visits
per calendar year
Durable medical The Plan pays 80 under High Option and 70 under Standard Option after a 100 equipment copayment per device for the rental repair and purchase of durable medical equipment A
purchase of durable medical equipment in excess of 300 must be supported by a letter of medical necessity and pre approved by the Plan to be covered See definition on page 40

Emergency room Non surgical medical treatment rendered in a hospital emergency room for any reason other than charges an accidental injury is covered as follows
PPO High Option The Plan pays 90 of the Standard Option The Plan pays 90 of negotiated rate after a 50 copay per access the negotiated rate after a 50 copay per
to care access to care
Non PPO High Option The Plan pays 80 of Standard Option The Plan pays 70 of reasonable and customary charges after a 50 reasonable and customary charges after a 50
copay per access to care copay per access to care
Hospice care Both Options pay 1 100 of covered charges up to 2,000 for each period of care for outpatient care from a hospice care program 2 150 per day up to 3,000 for each period of
care for inpatient care in a hospice
These benefits will be paid if the hospice care program begins after a person's primary doctor certifies terminal illness and life expectancy of six months or less and if any service or inpatient

hospice stay that is a part of the program is
ordered by the supervising doctor
charged by the hospice care program and
provided within six months from the date the person entered or re entered after a period of remission a hospice care program

Remission A remission is the halt or actual reduction in the progression of illness resulting in discharge from a hospice care program with no further expenses incurred A readmission within three months of
a prior discharge is considered as part of the same period of care A new period begins three months after a prior discharge with maximum benefits available

Bereavement Both Options pay 200 for family bereavement counseling and supportive services if the covered benefit family members receive these services from a hospice care program within three months
following the death of a covered family member who received hospice care benefits under the Plan

Immunizations Childhood Both Options pay 100 of reasonable and customary charges for childhood immunizations
recommended by the American Academy of Pediatrics for dependent children under age 22
Age 65 and over Both Options pay 100 of reasonable and customary charges for one annual influenza and one annual pneumoccocal vaccine

Skilled nursing When Medicare Part A is primary payer it pays first and has made payment Both Options facilities provide secondary benefits for the applicable Medicare Part A copayments in full

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Postmasters Benefit Plan 2000
Section 5 Benefits continued
Well child care Well child care including blood lead level screenings and routine office visits lab and X rays
for children through age 12 is payable up to 150 per child for High Option and up to 125 per child for Standard Option per calendar year

Prescription Drug Benefits
What is covered You may purchase the following medications and supplies prescribed by a doctor from either a pharmacy or by mail

Drugs that by Federal law of the United States require a doctor's prescription for their purchase
Insulin
Needles and syringes for the administration of covered medications
Contraceptive drugs and devices including Norplant

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

Nutritional supplements vitamins and minerals
Drugs to aid in smoking cessation other than those covered under the Smoking cessation benefit

From a pharmacy The Plan will cover up to a 30 day supply of covered drugs or supplies from participating retail pharmacies or from non participating retail pharmacies Call Postmasters Benefit Plan at
703 683 5585 or visit our website at http www postmasters org pbp asp to locate a participating retail pharmacy in your area

Participating High Option After the 50 calendar year Standard Option After the 50 calendar retail pharmacy drug deductible you pay to the pharmacy a 5 year drug deductible you pay to the pharmacy
copayment for generic and a 12 copayment a 10 copayment for generic and a 20 for name brand drugs per prescription or refill copayment for name brand drugs per
The Plan will pay the remainder of the prescription or refill The Plan will pay the discounted cost remainder of the discounted cost

An ID card will be sent to each member along with a list of participating retail pharmacies When you present the card you will be given a discount on your prescription You must show your
prescription drug card to receive the discount There is no claim form to file
Non participating High Option After the 100 calendar year Standard Option After the 100 calendar retail pharmacy drug deductible the Plan pays 80 of the year drug deductible the Plan pays 70 of
covered charge the covered charge
To claim benefits Obtain a receipt when you use a non participating pharmacy Receipts must include the
prescription number name of drug prescribing doctor's name date name and address of pharmacy or store where drug was purchased the number of days the supply covers patient's

name and charge Canceled checks or cash register receipts are not acceptable Use a HCFA 1500 claim form to claim benefits for prescription drugs and supplies you purchase You may obtain
these forms by calling 703 683 5585 Mail it to Postmasters Benefit Plan 1019 North Royal Street Alexandria VA 22314 1596

Waiver High Option When Medicare Part B is the Standard Option When Medicare Part B primary payer the Plan waives the 100 is the primary payer the Plan waives the
calendar year drug deductible for non 100 calendar year drug deductible for nonparticipating pharmacies and pays 80 The participating pharmacies and pays 70 The
Plan also waives the 50 calendar year drug Plan also waives the 50 calendar year drug deductible for participating pharmacies The deductible for participating pharmacies The
copayments of 5 or 12 for participating copayments of 10 and 20 for participating pharmacies are not waived pharmacies are not waived

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Postmasters Benefit Plan 2000
Section 5 Benefits continued
By Mail You may purchase up to a 90 day supply of maintenance drugs through the Mail Order Drug Program All drugs and supplies listed above are covered except for those that require constant
refrigeration are too heavy to mail or that must be administered by doctors in a clinical setting
Under the Mail Order Drug Program if a generic equivalent to the prescribed drug is available Merck Medco Services will dispense the generic equivalent instead of the name brand unless your

doctor specifies that the name brand is required
High Option You pay 5 for generic and Standard Option After a 50 calendar year 12 for name brand drugs drug deductible you pay 10 for generic and

20 for name brand drugs
Waiver High Option When Medicare Part B is the Standard Option When Medicare Part B
primary payer the Plan waives the 5 and is the primary payer the Plan waives the 12 copayments 50 calendar year drug deductible and the

10 and 20 copayments
Prescriber's choice When your mail order prescription is received it will be reviewed to determine if it is a program prescription that could be replaced with a more cost effective alternative medication or preferred
drug A pharmacist will contact your doctor and identify the cost effective alternative medication that is available If your doctor agrees to change your medication to this preferred drug at the time
your prescription is filled you will be sent a check for one half the amount of your applicable mail order drug copay

To claim benefits The Plan will send you information on the Mail Order 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 Services
4 Allow approximately two weeks for delivery

You'll receive forms for refills and future prescription orders each time you receive drugs or supplies under this Program In the meantime if you have any questions about a particular drug or

a prescription you may call Merck Medco Services toll free 1 800 631 7780 To request order forms you may call toll free 1 800 631 7780 or the Plan at 1 703 683 5585

Dental Benefits What is covered The Plan will pay actual charges up to the amount specified in the Schedule of dental allowances
under both Standard and High Options
Both Options Accidental The Plan pays covered charges up to the High Option Schedule of dental allowances for repair of
injury to teeth accidental injury see page 40 to sound natural teeth Injury to the teeth from chewing or biting is
not considered an accidental injury for purposes of this provision High Option

Basic services After satisfaction of a 30 dental deductible the Plan pays covered charges for basic services up to the applicable limit shown in the Schedule of dental allowances on pages 25 and 26

Major services After the 30 dental deductible the Plan pays covered charges up to a percentage of the applicable
limit shown in the Schedule of dental allowances on pages 26 and 27 This percentage depends upon the number of calendar years the member has been continuously enrolled under the High

Option of this Plan as follows first calendar year 50 of scheduled limit second calendar year 75 of scheduled limit thereafter 100 of scheduled limit

The maximum benefit payable for any calendar year is 800 per person 2,000 per family Only scheduled limits shown in the Schedule of dental allowances may be applied toward the dental
deductible or the maximums payable
The following Schedule of dental allowances for basic and major services is a complete list of covered dental services available under the High Option

Note The Plan pays actual charges up to the scheduled limits
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Postmasters Benefit Plan 2000
Section 5 Benefits continued
High Option basic services
ADA Scheduled ADA Scheduled Code Diagnostic Limit Code Endodontics Limit

0120 Periodic oral evaluation routine exams 3110 Pulp cap direct 9.50 limited to two per year 6.50 3120 Pulp cap indirect 9.50
0140 Limited oral evaluation problem focused 6.50 3220 Therapeutic pulpotomy 17.50 0150 Comprehensive oral evaluation 9.00 3310 Root canal one 108.00
0160 Detailed and extensive oral evaluation problem 3320 Root canal two 131.00 focused by report 11.00 3330 Root canal three or more 178.50
0210 Intraoral complete series including bitewings 3351 Apexification recalcification initial visit 7.00 limited to one every three years 23.00 3410 Apicoectomy periradicular surgery anterior 113.00
0220 Intraoral periapical first film 3.50 0230 Intraoral periapical each additional film 1.00 Periodontics
0240 Intraoral occlusal film 6.00 4210 Gingivectomy or gingivoplasty per quadrant 86.00 0250 Extraoral first film 7.00 4211 Gingivectomy or gingivoplasty per tooth 22.00
0260 Extraoral each additional film 7.00 4220 Gingival curettage surgical per quadrant by 0270 Bitewing single film 3.50 report 12.00
0272 Bitewings two films 6.50 4240 Gingival flap procedure including root planing 0274 Bitewings four films bitewings limited to two per quadrant 33.50
series per year 9.50 4249 Clinical crown lengthening hard tissue 90.00 0330 Panoramic film considered a complete 4260 Osseous surgery including flap entry and closure
series 19.00 per quadrant 194.00 0460 Pulp vitality tests 7.00 4263 Bone replacement graft first site in quadrant 84.00
0470 Diagnostic casts 15.50 4271 Free soft tissue graft procedure including donor site surgery 142.00
Preventive 4320 Provisional splinting intracoronal 33.50 1110 Prophylaxis adult age 14 or over 4321 Provisional splinting extracoronal 35.50
prophylaxes or cleanings are limited to two 4341 Periodontal scaling and root planing per per year 14.50 quadrant 15.00
1120 Prophylaxis child under age 14 prophylaxes 4910 Periodontal maintenance procedures following or cleanings are limited to two per year 10.50 active therapy 19.50
1201 Topical application of fluoride including prophylaxis 17.00 Prosthodontics removable repairs
1203 Topical application of fluoride prophylaxis not 5510 Repair broken complete denture base 26.00 included applications of fluoride limited to 5520 Replace missing or broken teeth complete
one per year and to children under age 14 6.50 denture each tooth 5.00 1510 Space maintainer fixed unilateral 77.50 5610 Repair resin denture base 25.00
1515 Space maintainer fixed bilateral 77.50 5620 Repair cast framework 34.00 1520 Space maintainer removable unilateral 113.50 5630 Repair or replace broken clasp 20.00
1525 Space maintainer removable bilateral 113.50 5640 Replace broken teeth per tooth 5.00 1550 Recementation of space maintainer space 5650 Add tooth to existing partial denture 11.00
maintainers are passive appliances schedule 5660 Add clasp to existing partial denture 24.00 limit includes all adjustments 10.00
Oral surgery includes local anesthesia and Restorative routine postoperative care
Note Multiple restorations on one surface will 7110 Extraction single tooth 17.00 be considered as a single restoration 7120 Extraction each additional tooth 14.50
2110 Amalgam one surface primary 13.50 7130 Root removal exposed roots 18.00 2120 Amalgam two surfaces primary 19.50 7210 Surgical removal of erupted tooth requiring
2130 Amalgam three surfaces primary 25.00 elevation of mucoperiosteal flap and removal 2140 Amalgam one surface permanent 14.50 of bone and or section of tooth 24.00
2150 Amalgam two surfaces permanent 22.00 7250 Surgical removal of residual tooth roots 2160 Amalgam three surfaces permanent 29.50 cutting procedure 28.50
2210 Silicate cement 18.00 7281 Surgical exposure of impacted or unerupted 2330 Resin one surface 17.00 tooth to aid eruption 46.50
2331 Resin two surfaces 24.00 7310 Alveoloplasty in conjunction with extractions 2332 Resin three surfaces 29.50 per quadrant 30.50
2951 Pin retention per tooth in addition to 7320 Alveoloplasty not in conjunction with restoration 10.50 extractions per quadrant 49.50

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Postmasters Benefit Plan 2000
Section 5 Benefits continued
High Option basic services continued
ADA Scheduled ADA Scheduled Code Oral surgery continued Limit Code Limit

7450 Removal of odontogenic cyst or tumor lesion 2810 Crown 3 4 cast metallic 198.50 diameter up to 1.25 cm 42.00
2910 Recement inlay 11.50 7451 Removal of odontogenic cyst or tumor lesion 2920 Recement crown 11.50

diameter over 1.25 cm 94.50 2930 31 Prefabricated stainless steel crown primary or 7510 Incision and drainage of abscess intraoral soft
permanent tooth 40.00 tissue 24.50 2932 Prefabricated resin crown 40.00

7520 Incision and drainage of abscess extraoral soft 2940 Sedative filling 8.00 tissue 24.50
2950 Core buildup including any pins 2.00 7970 Excision of hyperplastic tissue per arch 67.00 2952 Cast post and core in addition to crown 56.50

7971 Excision of pericoronal gingiva 28.50 2954 Prefabricated post and core in addition to
crown 32.00 Adjunctive general services 2970 Temporary crown fractured tooth 40.00

9220 General anesthesia 45.00 9230 Analgesia 9.00
Prosthodontics removable 9240 Intravenous sedation 43.00 5110 20 Complete upper or lower denture 242.50

9310 Consultation diagnostic service provided by 5130 40 Immediate upper or lower denture 275.00 dentist or physician other than practitioner
5211 Maxillary partial denture resin including providing treatment 18.00 any conventional clasps rest and teeth 237.50

9430 Office visit for observation during regularly 5212 Mandibular partial denture resin base scheduled hours 6.50
including any conventional clasps rest 9440 Office visit after regularly scheduled hours 8.00 and teeth 237.50

9950 Occlusion analysis mounted case 17.50 5213 Maxillary partial denture cast metal 9951 Occlusal adjustment limited 25.00
framework with resindenture bases 9952 Occlusal adjustment complete 110.00 including any conventional clasps and

teeth 271.00 5214 Mandibular partial denture cast metal
High Option major services framework with resin denture bases
including any conventional clasps rest ADA Scheduled and teeth 271.00

Code Restorative Limit 5281 Removable unilateral partial denture one 2410 Gold foil one surface 24.50 piece cast metal including clasp and
2420 Gold foil two surfaces 53.50 teeth 157.50 2430 Gold foil three surfaces 74.50 5410 11 Adjust complete upper or lower denture 17.00
2510 Inlay metallic one surface 40.00 5421 22 Adjust partial upper or lower denture 17.00 2520 Inlay metallic two surfaces 92.50 5710 11 Rebase complete denture 94.50
2530 Inlay metallic three or more surfaces 117.50 5720 21 Rebase partial denture 71.00 2610 Inlay porcelain ceramic one surface 24.50 5730 31 Reline complete denture chairside 56.50
2620 Inlay porcelain ceramic two surfaces 45.00 5740 41 Reline partial denture chairside 43.00 2630 Inlay porcelain ceramic three or more 5750 51 Reline complete denture laboratory 76.00
surfaces 69.00 5760 61 Reline partial denture laboratory 65.00 2710 Crown resin laboratory 73.50 5810 11 Interim complete denture 115.50
2720 Crown resin with high noble metal 198.50 5820 21 Interim partial denture 65.00 2721 Crown resin with predominantly base 5850 Tissue conditioning per denture unit 20.00
metal 167.00 5860 Overdenture complete by report 350.00 2722 Crown resin with noble metal 182.50 5861 Overdenture partial by report 280.00
2740 Crown porcelain ceramic substrate 184.00 5862 Precision attachment by report 98.00 2750 Crown porcelain fused to high noble
Prosthodontics fixed metal 215.50 6210 Pontic cast high noble metal 204.00
2751 Crown porcelain fused to predominantly 6211 Pontic cast predominantly base metal 172.00 base metal 184.00
6212 Pontic cast noble metal 188.00 2752 Crown porcelain fused to noble metal 199.50 6240 Pontic porcelain fused to high noble metal 215.50
2790 Crown full cast high noble metal 203.50 6241 Pontic porcelain fused to predominantly 2791 Crown full cast predominantly base metal 172.00
base metal 184.00 2792 Crown full cast noble metal 188.00

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Postmasters Benefit Plan 2000
Section 5 Benefits continued
High Option major services continued
ADA Scheduled ADA Scheduled Code Prosthondontics fixed continued Limit Code Limit

6242 Pontic porcelain fused to noble metal 199.50 6752 Crown porcelain fused to noble metal 205.00 6250 Pontic resin with high noble metal 222.00 6780 Crown 3 4 cast high noble metal 198.50
6251 Pontic resin with predominantly base metal 175.00 6790 Crown full cast high noble metal 209.00 6252 Pontic resin with noble metal 197.00
6791 Crown full cast predominantly base metal 187.00 6520 Inlay metallic two surfaces 92.50 6792 Crown full cast noble metal 185.00

6530 Inlay metallic three or more surfaces 117.50 6930 Recement fixed partial denture 21.00 6545 Retainer Cast metal for resin bonded fixed
6940 Stress breaker 56.50 prosthetics 34.00 6950 Precision attachment 92.50

6720 Crown resin with high noble metal 215.50 6970 Cast post and core in addition to fixed partial 6721 Crown resin with predominantly base metal 184.00
denture retainer 66.00 6722 Crown resin with noble metal 199.50 6971 Cast post as part of fixed partial denture

6750 Crown porcelain fused to high noble metal 234.00 retainer 51.00 6751 Crown porcelain fused to predominantly
6972 Prefabricated post and core in addition to base metal 185.00 fixed partial denture retainer 37.00

Standard Option The Plan covers charges up to the applicable limit shown in the following Schedule of dental allowances There is no calendar year maximum or deductible This is a complete list of covered
services
ADA Scheduled Code Diagnostic Limit

0120 Periodic oral evaluation routine limited to two per year 6.50 0140 Limited oral evaluation problem focused 6.50
0150 Comprehensive oral evaluation 9.00 0210 Intraoral complete series including bitewings limited to one every three years 15.00
0220 Intraoral periapical first film 1.00 0230 Intraoral periapical each additional film 1.00
0240 Intraoral occlusal film 7.50 0270 Bitewing single film 3.00
0272 Bitewings two films 4.00 0274 Bitewings four films bitewings limited to two series per year 6.50
0330 Panoramic film considered a complete series 15.00
Preventive 1110 Prophylaxis adult age 14 or over prophylaxes or cleanings are limited to two per year 10.50
1120 Prophylaxis child under age 14 prophylaxes or cleanings limited to two per year 10.50 1201 Topical application of fluoride including prophylaxis 16.00
1203 Topical application of fluoride prophylaxis not included application of fluoride limited to one per year and to children under age 14 5.50

Restorative Note Multiple restorations in one surface will be considered as a single restoration
2110 Amalgam one surface primary 11.50 2120 Amalgam two surfaces primary 16.50
2130 Amalgam three surfaces primary 22.00 2140 Amalgam one surface permanent 11.50
2150 Amalgam two surfaces permanent 18.00 2160 Amalgam three surfaces permanent 22.00
2210 Silicate cement 16.50 2330 Resin one surface 11.50
2331 Resin two surfaces 18.00 2332 Resin three surfaces 22.00

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Postmasters Benefit Plan 2000
Section 5 Benefits continued
Standard Option continued
ADA Scheduled Code Oral surgery Limit

7110 Extraction single tooth 12.50 7120 Extraction each additional tooth 7.50
7210 Surgical removal of erupted tooth requiring elevation of mucoperiosteal flap and removal of bone and or section of tooth 19.00

Related benefit Oral and For covered oral and maxillofacial surgery see page 16
maxillofacial surgery

What is not covered Services and supplies furnished by other than a licensed dentist except for a prophylaxis cleaning which may be performed by a licensed dental hygienist working under the
supervision of a dentist or in an accredited school of dentistry
Dental services and supplies for which other benefits are payable under this Plan
Replacement of bridges dentures or appliances within five years of coverage of previous placement by this Plan

Fluorides for home use
Dental implants
Any dental service or supply for cosmetic purposes
Training in preventive care oral hygiene or dietary practices
Orthodontic treatment

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Non FEHB Benefits Available to Plan Members
The benefits described under Non FEHB benefits are neither offered nor guaranteed under the contract with the FEHB Program but are made available to all enrollees and family members of this Plan The cost of NonFEHB

benefits is not included in the FEHB premium and any charges for these services do not count toward any FEHB deductibles out of pocket maximum copayment charges etc These benefits are not subject to the
FEHB disputed claims review procedure

Long term What would happen if you suddenly required nursing home care The League offers care immediate care without the red tape Benefits are paid in addition to what you may
qualify for through Medicare's skilled nursing home benefits Premiums remain the same regardless of your age For current information please call 1 800 321 0102

Supplemental All members of the League may enroll in the League Dental Program The League does Dental not require enrollment in the FEHB Plan for enrollment in the League Dental Program
The League Dental Program provides up to 1,000 of benefits per year With the League Dental Program you do not have to change from your current dentist This program
pays benefits directly to you or to your dentist Members may enroll in one of the three levels of coverage individual self and spouse or family Enrollees pay premiums
quarterly Coverage becomes effective the first of the month following receipt of your completed application and quarterly premium For more information about benefits
limitations and premiums and to request an application write to League Insurance Services 4800 Montgomery Lane M25 Bethesda MD 20814 To get information by
telephone call toll free 1 800 522 1857

Eyewear Outlook Vision Services Program offers you and your entire family all the saving program advantages available only to Outlook Vision Services members Outlook Vision Services
offers a choice of over 6000 Professional Vision Care Providers in all 50 States and Puerto Rico The Network is comprised of well known national and regional vision care
centers independent optometrists or opticians such as most
JC Penney Optical Montgomery Ward Royal Optical Sears Pearl Vision For Eyes Only Sterling Optical Eye Masters and many more

Best of all as a member you can save up to 50 off the retail price of
Prescription Glasses and Sunglasses Choose from all frames in stock

Contact Lenses even Mail Order
Nonprescription Sunglasses
Accessories

Members will be able to purchase what they want where they want and at a very reasonable price For more information contact Outlook Vision Services at

Guardian Eagle Corporation P O Box 84415
Sioux Falls SD 57118
Customer Service 1 800 342 7188

Non FEHBP Benefits are not part of the FEHB contract
29 29
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Postmasters Benefit Plan 2000
Section 6 How to File a Claim
Claim forms If you do not receive your identification card s within 60 days after the effective date of your identification cards enrollment call the Carrier at 703 683 5585 to report the delay In the meantime use your copy
and questions of the SF 2809 enrollment form or your annuitant confirmation letter from OPM as proof of enrollment when you obtain services This is also the number to call for claim forms or advice on
filing claims
If you have a question concerning Plan benefits contact the Carrier at 703 683 5585 or you may write the Carrier at 1019 North Royal Street Alexandria VA 22314 1596

If you made your open season change by using Employee Express and have not received your new ID card by the effective date of your enrollment call the Employee Express HELP number to
request a confirmation letter Use that letter to confirm your new coverage with providers
How to file claims Claims filed by your doctor that include an assignment of benefits to the doctor are to be filed on the form HCFA 1500 Health Insurance Claim Form The claim form must be signed to authorize
release of medical information and assignment of benefits A Signature on File is acceptable Claims submitted by enrollees may be submitted on the HCFA 1500 or a claim form that includes
the information shown below Bills and receipts should be itemized and show
Name of patient and relationship to enrollee
Plan identification number of enrollee
Name and address of person or firm providing the service or supply
Provider's tax identification number needed for assigned claims and PPO providers
Dates that services or supplies were furnished
Type of each service or supply and the charge
Diagnosis

In addition
All requests for additional information needed by the Plan should be responded to promptly
For claims under Other Medical Benefits the attending doctor must complete a doctor's statement

A copy of the explanation of benefits EOB from any primary payer such as Medicare must be sent with your claim
Bills for private duty nurses must show that the nurse is a registered or licensed practical nurse and should include nursing notes
Claims for rental or purchase of durable medical equipment in excess of 300 private duty nursing and physical occupational and speech therapy require a written statement from the
doctor specifying the medical necessity for the service or supply and the length of time needed
Claims for overseas foreign services should include an English translation Charges should be converted to U S dollars using the exchange rate applicable at the time the expense was

incurred
For dental claims complete the member's section of the claim form and give it to the dentist to complete the remainder

For prescription drug claims see pages 23 and 24
Canceled checks cash register receipts or balance due statements are not acceptable
After completing and signing a claim form and attaching proper documentation send claims to
Postmasters Benefit Plan 1019 North Royal Street

Alexandria VA 22314 1596 Telephone 703 683 5585

Records Keep a separate record of the medical expenses of each covered family member as deductibles and maximum allowances apply separately to each person Save copies of all medical bills
including those you accumulate to satisfy a deductible In most instances they will serve as evidence of your claim The Carrier will not provide duplicate or year end statements

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Postmasters Benefit Plan 2000
Section 6 How to File a Claim continued
Submit claims When covered expenses exceed the deductible complete a claim form attach itemized bills and promptly send them to the Plan Claims for out of hospital benefits should not be submitted more often
than quarterly To avoid denial all claims must be submitted no later than December 31 of the calendar year after the year in which the covered service was provided unless timely filing was
prevented by administrative operations of Government or legal incapacitation provided the claim was submitted as soon as reasonably possible If the Plan returns a claim or part of a claim for
additional information it must be resubmitted within 90 days or before the timely filing period expires whichever is later Once benefits have been paid there is a three year limitation on the
reissuance of uncashed checks

Direct payment to To authorize direct payment to a hospital doctor or dentist complete the authorization on the hospital or provider claim form or on the assignment form furnished by the hospital doctor or dentist
of care

When more Reply promptly when the Carrier requests information in connection with a claim If you do not information is respond the Carrier may delay processing or limit the benefits available
needed
Privacy Act If you ask OPM to review a denial of a claim for payment or service OPM is authorized by statement chapter 89 of title 5 U S C to use the information collected from you and the Carrier to
determine if the Carrier has acted properly in denying you the payment or service and the information so collected may be disclosed to you and or the Carrier in support of OPM's
decision on the disputed claim

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Postmasters Benefit Plan 2000
Section 7 General exclusions Things we don't cover

The exclusions in this section apply to all benefits Exclusions that are primarily identified with a single benefit category are listed along with that benefit category but may apply to other categories Therefore please refer to the specific benefit
sections as well to assure that you are aware of all benefit exclusions Although we may list a specific service as a benefit we will not cover it unless we determine it is medically necessary to prevent diagnose or treat your illness or condition The fact
that a covered provider has prescribed recommended or approved a service or supply does not make it medically necessary or eligible for coverage under this Plan

We do not cover Services drugs or supplies that are not medically necessary the following
Services not required according to accepted standards of medical dental or psychiatric practice in the United States

Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the

result of an act of rape or incest
Procedures services drugs and supplies related to sex transformations sexual dysfunction or sexual inadequacy

Services or supplies you receive from a provider or facility barred from the FEHB Program
Expenses you incurred while you were not enrolled in this Plan
Charges that would not be made if the covered individual had no health insurance coverage
Services furnished without charge except as described on page 36 services rendered while in active military service or services required for an illness or injury sustained on or after the

effective date of enrollment 1 as a result of an act of war within the United States its territories or possessions or 2 during combat

Services furnished by immediate relatives or household members such as a spouse parent child brother or sister by blood marriage or adoption
Services furnished or billed by a noncovered facility except that medically necessary prescription drugs are covered
Services not specifically listed as covered
Services provided in connection with a noncovered service
Any portion of a provider's fee or charge ordinarily due from the enrollee but that has been waived If a provider routinely waives does not require the enrollee to pay a deductible

copay or coinsurance the Carrier will calculate the actual provider fee or charge by reducing the fee or charge by the amount waived

Charges the enrollee or Plan has no legal obligation to pay such as excess charges for an annuitant age 65 or older who is not covered by Medicare Parts A and or B see page 37
doctor charges exceeding the amount specified by the Department of Health and Human Services when benefits are payable under Medicare limiting charge see page 35 or State
premium taxes however applied
Routine preventive care immunizations and all related expenses except as provided on pages 19 20 and 22

Treatment for weight control or reduction except morbid obesity
Social recreational and educational services or training
Treatment of corns calluses and foot subluxations
Therapy for developmental delays learning disabilities stuttering tongue thrusting or deviate swallowing

Treatment of temporomandibular joint disorder
Services rendered by Christian Scientist providers including sanitoriums
Services rendered by massage therapists rolfers myotherapists and trager clinics
Services rendered by hypnotherapists neuromuscular therapists and naturopaths
Hospital benefits for admissions required for surgical procedures excluded by this Plan and
Interest completion of claim forms or similar administrative charges made by providers

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Postmasters Benefit Plan 2000
Section 8 Limitations Rules that affect your benefits
All benefits are subject to the definitions limitations and exclusions in this brochure Coverage is provided only for services and supplies that are listed in this brochure

Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On
occasion you may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled with us

If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a Medicare Choice plan when one is available in your area For information on
suspending your FEHB enrollment and changing to a Medicare Choice plan contact your retirement office If you later want to re enroll in the FEHB Program generally you may
do so only at the next Open Season
If you involuntarily lose coverage or move out of the Medicare Choice service area you may re enroll in the FEHB Program at any time

If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration SSA office or call SSA at 1 800 638 6833

Coordinating The following information applies only to enrollees and covered family members who are benefits
entitled to benefits from both this Plan and Medicare You must disclose information about Medicare coverage including your enrollment in a Medicare prepaid plan to this Carrier this

applies whether or not you file a claim under Medicare You must also give this Carrier authorization to obtain information about benefits or services denied or paid by Medicare when
they request it It is also important that you inform the Carrier about other coverage you may have as this coverage may affect primary secondary status of this Plan and Medicare see pages
35 36
This Plan covers most of the same kinds of expenses as Medicare Part A hospital insurance and Part B medical insurance except that Medicare does not cover prescription drugs

The following rules apply to enrollees and their family members who are entitled to benefits from both a FEHB Plan and Medicare

This Plan is 1 You are age 65 or over have Medicare Part A or Parts A and B and are employed by the primary if Federal Government
2 Your covered spouse is age 65 or over and has Medicare Part A or Parts A and B and you are employed by the Federal Government
3 The patient you or a covered family member is within the first 30 months of eligibility to receive Medicare Part A benefits due to End Stage Renal Disease ESRD except when
Medicare based on age or disability was the patient's primary payer on the day before he or she became eligible for Medicare Part A due to ESRD or

4 The patient you or a covered family member is under age 65 and eligible for Medicare solely on the basis of disability and you are employed by the Federal Government

For purposes of this section employed by the Federal Government means that you are eligible for FEHB coverage based on your current employment and you do not hold an appointment
described under Rule 6 of the following Medicare is primary section

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Postmasters Benefit Plan 2000
Section 8 Limitations Rules that affect your benefits continued
Medicare is 1 You are an annuitant age 65 or over covered by Medicare Part A or Parts A and B and are primary if not employed by the Federal Government

2 Your covered spouse is age 65 or over and has Medicare Part A or Parts A and B and you are not employed by the Federal Government
3 You are age 65 or over and a you are a Federal judge who retired under title 28 U S C b you are a Tax Court judge who retired under Section 7447 of title 26 U S C or c you
are the covered spouse of a retired judge described in a or b
4 You are an annuitant not employed by the Federal Government and either you or a covered family member who may or may not be employed by the Federal Government is under age

65 and eligible for Medicare on the basis of disability
5 You are enrolled in Part B only regardless of your employment status
6 You are age 65 or over and employed by the Federal Government in an appointment that excludes similarly appointed nonretired employees from FEHB coverage and have Medicare

Part A or Part A and B
7 You are a former Federal employee receiving workers compensation and the Office of Workers Compensation has determined that you are unable to return to duty

8 The patient you or a covered family member has completed the 30 month ESRD coordination period and is still eligible for Medicare due to ESRD or
9 The patient you or a covered family member becomes eligible for Medicare due to ESRD after Medicare assumed primary payer status for the patient under rules 1 through 7 above

When Medicare is When Medicare is primary all or part of your Plan deductibles and coinsurance will be waived primary as follows
Inpatient Hospital Benefits If you are enrolled in Medicare Part A the Plan will waive the deductible and coinsurance
Surgical Benefits If you are enrolled in Medicare Part B the Plan will waive the deductible and coinsurance applicable to surgical and medical care
Mental Conditions Substance Abuse Benefits If you are enrolled in Medicare Part A the Plan waives the inpatient deductible and coinsurance for hospital charges If you are enrolled in
Medicare Part B the Plan waives the deductible and coinsurance for doctors inpatient services and outpatient care

Other Medical Benefits If you are enrolled in Medicare Part B the Plan waives the calendar year deductible and coinsurance
Prescription Drug Benefits If you are enrolled in Medicare Part B the Plan waives the Prescription Drug deductibles for retail pharmacies The coinsurance for non participating
pharmacies is not waived The copayments for participating retail pharmacies are not waived The Mail Order Drug Program copayments are waived for both options The Mail Order Drug
deductible is also waived for Standard Option
Additional Benefits If you are enrolled in Medicare Part B the Plan waives the 100 copayment for Durable Medical Equipment and the 50 copayment and coinsurance for

Emergency Room Treatment
Dental Benefits The deductible is not waived

When Medicare is the primary payer this Plan will limit its payment to an amount that supplements the benefits that would be payable by Medicare regardless of whether or not

Medicare benefits are paid However the Plan will pay its regular benefits for emergency services to an institutional provider such as a hospital that does not participate with Medicare
and is not reimbursed by Medicare
If you are enrolled in Medicare you may be asked by a physician to sign a private contract agreeing that you can be billed for services that would ordinarily be covered by Medicare

Should you sign such an agreement Medicare will not pay any portion of the charges and you may receive less or no payment for those services under this Plan

34 34
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Postmasters Benefit Plan 2000
Section 8 Limitations Rules that affect your benefits continued
When you also enroll When you are enrolled in a Medicare prepaid plan while you are a member of this Plan you may in a Medicare continue to obtain benefits from this Plan If you submit claims for services covered by this Plan
prepaid plan that you receive from providers that are not in the Medicare plan's network the Plan will not waive any deductibles or coinsurance when paying these claims

Medicare's payment If you are covered by Medicare Part B and it is primary you should be aware that your out ofpocket and this Plan costs for services covered by both this Plan and Medicare Part B will depend on whether
your doctor accepts Medicare assignment for the claim
Doctors who participate with Medicare accept assignment that is they have agreed not to bill you for more than the Medicare approved amount for covered services Some doctors who do not

participate with Medicare accept assignment on certain claims If you use a doctor who accepts Medicare assignment for the claim the doctor is permitted to bill you after the Plan has paid
only when the Medicare and Plan payments combined do not total the Medicare approved amount

Doctors who do not participate with Medicare are not required to accept direct payment or assignment from Medicare Although they can bill you for more than the amount Medicare would
pay Medicare law the Social Security Act 42 U S C sets a limit on how much you are obligated to pay This amount called the limiting charge is 115 percent of the Medicare approved
amount Under this law if you use a doctor who does not accept assignment for the claim the doctor is permitted to bill you after the Plan has paid only if the Medicare and Plan payments
combined do not total the limiting charge Neither you nor your FEHB Plan is liable for any amount in excess of the Medicare limiting charge for charges of a doctor who does not participate
with Medicare The Medicare Summary Notice MSN form will have more information about this limit

If your doctor does not participate with Medicare asks you to pay more than the limiting charge and he or she is under contract with this Plan call the Plan If your doctor is not a Plan doctor
ask the doctor to reduce the charge or report him or her to the Medicare carrier that sent you the Medicare MSN form In any case a doctor who does not participate with Medicare is not entitled
to payment of more than 115 percent of the Medicare approved amount

Medicare If you are enrolled in a Medicare HMO and obtain care from a non HMO provider and the HMO HMO's will not pay for the care the Plan will base allowable charges on the Medicare limiting charge
and apply the appropriate deductibles and pay regular benefits

How to claim In most cases when services are covered by both Medicare and this Plan Medicare is the primary benefits payer if you are an annuitant and this Plan is primary if you are an employee When Medicare is
the primary payer your claims should first be submitted to Medicare After Medicare has paid its benefits the Carrier will consider the balance of any covered expenses To be sure your claims
are processed by this Carrier you must submit the MSN form from Medicare and duplicates of all bills along with a completed claim form The Carrier will not process your claim without knowing
whether you have Medicare and if you do without receiving the Medicare MSN

Overpayments The Carrier will make reasonably diligent efforts to recover benefit payments made erroneously but in good faith and may apply subsequent benefits otherwise payable to offset any
overpayments

Other group When anyone has coverage with us and with another group health plan it is called double insurance coverage coverage You must tell us if you or a family member has double coverage You must also send
us documents about other insurance if we ask for them
When you have double coverage one Plan is the primary payer it pays benefits first The other Plan is secondary it pays benefits next We decide which insurance is primary according to the

National Association of Insurance Commissioners Guidelines
If we pay second we will determine how much of the charge we will pay After the first Plan pays we will pay either what is left of the reasonable charge or our regular benefit whichever is

less We will not pay more than the reasonable charge
35 35
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Postmasters Benefit Plan 2000
Section 8 Limitations Rules that affect your benefits continued
When benefits are payable under automobile insurance including no fault the automobile insurer is primary pays its benefits first if it is legally obligated to provide benefits for health care
expenses without regard to other health benefits coverage the enrollee may have
Remember If you have double coverage you must tell us that you have double coverage If we determine that we are secondary we must have a copy of the primary Plan's explanation of

benefits EOB before we can determine how much we will pay
When others are responsible for

injuries
Liability insurance Subrogation applies when you are sick or injured as a result of the act or omission of another and third party
person or party Subrogation means the Plan's right to recover any payments made to you or a actions family member by a third party's insurer because of an injury or illness caused by a third party

Third party means another person or organization If as a result of an illness or injury for which the Plan has paid or may pay benefits you institute a suit or claim against a third party the Plan
will take an assignment from you of the money damages paid or payable to you by any third party on the suit or claim This means the Plan will assert a lien against any monies you receive
as a result of your claim regardless of the year instituted whether you receive money by court order or as an out of court settlement or any other type of settlement The lien will apply to
money proceeds in the full amount of the Plan benefits paid or payable to you or any covered member of your family and it will act only to reimburse the Plan for its payment of such benefits

Upon notification the Plan will provide you with the necessary forms and will insist on execution of the assignment before paying any benefits on account of the injury or illness Failure to notify