Sponsored by the Association
For Changesin 6 7 benefitssee
pages
Who may enroll in this Plan Members of the Association
Annuitants retirees who are members of the Association may enroll in this Plan
Enrollment code for this Plan
421 Self Only 422 Self and Family
Visit the OPM website at http www opm gov insure
Authorized for distribution by the
United States Office of
Personnel Management Federal Employees Health Benefits Program
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Table of Contents
Introduction 3
Plain Language 3
How to use this brochure 4
Section 1 Fee For Service Plans 5
Section 2 How we change for 2000 6
Section 3 How to get benefits 8
Section 4 What if we deny your claim or request for pre authorization 16
Section 5 Benefits 19
Section 6 How to file a claim 35
Section 7 General exclusions Things we don't cover 37
Section 8 Limitations Rules that affect your benefits 38
Section 9 Fee for Service Facts 44
Section 10 FEHB Facts 51
Inspector General Advisory Stop Healthcare Fraud 55
Index 56
Summary of Benefits 57
Premiums 59
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Association Benefit Plan
Introduction
This brochure describes the benefits you can receive from the Association Benefit Plan under the Government Employees Health Association's contract CS 1065 with the
Office of Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law The Plan is underwritten by Mutual of Omaha 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 6 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 Association Benefit Plan as this Plan throughout this brochure even though in other legal documents you see a plan referred to as a carrier
Sections one two four and ten are now in plain language as well as portions of sections three and eight We will rewrite the remaining sections of this brochure including the
benefits section for year 2001 Please note that the format and organization of this brochure have changed as well
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
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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 to deny your
request for a service
5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations
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 pre certification 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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Section 1 Fee for Service Plans
Fee for service plans reimburse you or your provider for covered services They do not typically provide or arrange for health care Fee for service plans let you choose your
own physicians hospitals and other health care providers
The FFS plan reimburses you for your health care expenses usually on a percentage basis These percentages as well as deductibles methods for applying deductibles to
families and the percentage of coinsurance you must pay vary by plan The type and extent of covered services vary by plan There is a detailed explanation of the benefits we
offer in this brochure you should read it carefully
This FFS plan offers a preferred provider organization PPO arrangement This arrangement with health care providers gives you enhanced benefits or limits your out ofpocket
expenses
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Section 2 How we change for 2000
Program wide This year you have a right to more information about this Plan care changes management our networks facilities and providers
If you have a chronic or disabling condition or are in the second or third trimester of pregnancy and your provider is leaving our PPO network at
our request without cause we will notify you You may continue to receive our PPO level benefits for your specialist's services for up to 90
days after you receive notice We will provide regular non PPO benefits for the specialist's services after the 90 day period expires
You may review and obtain copies of your medical records on request If you want copies of your medical records ask your health care provider
for them You may ask that a physician amend a record that is not accurate not relevant or incomplete If the physician does not amend
your record you may add a brief statement to it If they do not provide you your records call us and we will assist you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This screening is for colorectal cancer
Changes to the This has added the following optional hospital and physician Preferred Plan Provider Organization PPO network areas
In Alaska the county of Anchorage
In California the following counties Alameda Amador Butte
Calaveras Colusa Contra Costa Del Norte El Dorado Fresno
Glenn Humboldt Imperial Inyo Kern Kings Lake Los Angeles
Madera Marin Mariposa Mendocino Merced Mono Monterey
Napa Nevada Orange Placer Plumas Riverside Sacramento San
Benito San Bernadino San Diego San Francisco San Juaquin San
Luis Obispo San Mateo Santa Barbara Santa Clara Santa Cruz
Shasta Solano Sonoma Stanislaus Sutter Tehama Trinity
Tulare Tuolumne Vbentura Yolo and Yuba
In Florida the following counties Brevard Broward Charlotte
Citrus Collier Dade DeSoto Glades Hardee Hendry Hernando
Highlands Hillsborough Indian River Lake Lee Manatee Martin
Monroe Okeechobee Orange Osceola Palm Beach Pasco
Pinellas Polk Saint Lucie Sarasota Seminole Sumter and
Volusia
In Idaho the following counties Benewah Bonner Boundary
Clearwater Kootenai Latah Lewis Nez Perce and Shoshone
In Washington the following counties Adams Asotin Benton
Chelan Clallam Columbia Cowlitz Douglas Ferry Franklin
Garfield Grant Grays Harbor Island Jefferson King Kitsap
Kittias Klickitat Lewis Lincoln Mason Okanogan Pacific Pend
Oreille Pierce San Juan Skagit Skamania Snohomish Spokane
Stevens Thurston Wahkiakum Walla Walla Whatcom Whitman
and Yakima
For enrollees residing in the PPO Network Area and using nonparticipating facilities or providers the catastrophic limit is now 3,000
For enrollees residing in the PPO Network Area who are using nonparticipating facilities or providers the Plan pays 75 of the reasonable
and customary charges subject to the 250 deductible
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Section 2 How we change for 2000 continued
Copayments for prescription drugs purchased at a pharmacy have been increased as follows
12 for generic drugs or brand name when generic drugs are not available
24 for brand name drugs when generic drugs are available
Copayments for prescription drugs purchased by mail have been increased as follows
17 for generic drugs or brand name when generic drugs are not available
34 for brand name drugs when generic drugs are available
For Medicare B enrollees copayments now are required for generic prescription drugs or brand name drugs when generic drugs are not
available Copayments are as follows
When purchased from a pharmacy 5 copay is required for generic drugs or brand name drugs when generic drugs are not available
When purchased by mail 10 copay is required for generic drugs or brand name drugs when generic drugs are not available
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Section 3 How to get benefits
How do I keep my FEHB plans are expected to manage their costs prudently All FEHB health care plans have cost containment measures in place All fee for service plans
expenses down 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 costs
You can help 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
Pre certification Pre certification evaluates the medical necessity of proposed admissions and the number of days required to treat your condition You are
responsible for ensuring that the pre certification requirement is met You or your doctor must check with Mutual of Omaha's Care Review Unit
before being admitted to the hospital If that doesn't happen your Plan will reduce benefits by 500 except for Hospice Care Skilled Nursing
Facility Care and Home Health Care where failure to pre certify will result in disqualification of higher paid benefit levels 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 44 of this brochure
Flexible benefits Under the flexible benefits option the Carrier has the authority to option determine the most effective way to provide services The Carrier may
identify medically appropriate alternatives to traditional care and coordinate the provision of Plan benefits as a less costly alternative
benefit Alternative benefits are subject to ongoing review The Carrier may decide to resume regular contract benefits at its sole discretion
Approval of an alternative benefit is not a guarantee of any future alternative benefits The decision to offer an alternative benefit is solely
the Carrier's and may be withdrawn at any time It is not subject to OPM review under the disputed claims process
PPO The Plan has entered into an agreement with Mutual of Omaha's Preferred Provider Organization PPO This is a group of doctors and
hospitals that has contracted with Mutual to provide medical services at reduced costs Each time you need medical care by a doctor or hospital
you have the choice to use a health care provider who participates in the network or one who does not Regardless of the provider you choose
benefits will be subject to all terms conditions and limitations of the Plan In addition the Carrier does not supervise control or guarantee the
health care services of any preferred provider or other provider
How much do I You must share the cost of some services These cost sharing measures pay for services include deductibles coinsurance and copayments These and other
measures are described in more detail below
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 250 in covered charges you must pay each year before the Plan starts paying Other Medical Benefits Other
charges also apply to this deductible covered inpatient and outpatient visits for the treatment of mental conditions and visits for extended
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Section 3 How to get benefits continued
dental treatment of accidental dental injuries You are responsible for the payment of all charges that are applied to the calendar year deductible
There is a separate calendar year deductible for each member of your family
Family limit There is a separate calendar year deductible of 250 per person Under a family enrollment the deductible is considered satisfied and benefits are
payable for all family members when the expenses applied to the calendar year deductible for all family members reach 500
Furthermore if two or more covered members of your family are injured in the same accident you need to meet only one calendar year deductible
for those members in that calendar year for all expenses related to the accident
Hospital There is a separate hospital deductible of 100 per person per admission Admission for inpatient hospital expenses for non PPO admissions in the PPO
Network Area and for all admissions elsewhere
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 got 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
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 85 of
reasonable and customary charges for a covered service you are responsible for 15 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 75 for a service but the Plan's reasonable and customary allowance is 60 the Plan will pay 85 of the allowance
51 You must pay the 15 coinsurance 9 plus the difference between the actual charge and the reasonable and customary allowance
15 for a total member responsibility of 24
If provider waives If a provider routinely waives does not require you to pay your share of your share the charge for services rendered the Plan is not obligated to pay the full
percentage of the amount of the charge it would otherwise have paid of the provider's original charge 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 waives the 10 coinsurance the
actual charge is 90 The Plan will pay 81 90 of the actual charge of 90
Copayment A copayment is the stated amount the Plan may request you to pay for a covered service such as 17 copay per prescription by mail
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Section 3 How to get benefits continued
Lifetime Substance abuse coverage is limited to three inpatient or outpatient maximums treatment programs including aftercare per person per lifetime See
page 25
Hospice care has a lifetime maximum benefit of 7,500 per person if precertified If not pre certified the maximum allowable benefit is 4,500
See page 25
One smoking cessation program per person is covered per lifetime See page 28
Diagnosis and treatment of infertility has a lifetime maximum benefit of 5,000 See page 28
Do I have to You usually do not have to submit claims to us if you use preferred submit claims providers If you file a claim please send us all of the documents for your
claim as soon as possible You must submit claims no more than two years after the date the expense was incurred 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 health care provider
Covered facilities
Birthing A licensed facility that is equipped and operated solely to provide Center prenatal care to perform uncomplicated spontaneous deliveries and to
provide immediate post partum care
Day care A facility licensed as a day care center and that provides a planned Center program of psychiatric services for patients with mental conditions who
must spend their days but not nights under psychiatric supervision and that is not for schooling custodial recreational or training services
Hospice A facility that meets all of the following
1 primarily provides inpatient hospice care to terminally ill persons
2 is certified by Medicare as such or is licensed or accredited as such by the jurisdiction it is in
3 is supervised by a staff of M D s or D O s at least one of whom must be on call at all times
4 provides 24 hour a day nursing services under the direction of a R N and has a full time administrator and provides an ongoing quality
assurance program
Hospital 1 An institution that is accredited as a hospital under the hospital accreditation program of the Joint Commission on Accreditation of
Healthcare Organizations JCAHO or
2 Any other institution that is operated pursuant to law under the supervision of a staff of doctors and with 24 hour a day nursing
service and that is primarily engaged in providing
a General patient care and treatment of sick and injured persons through medical diagnostic and major surgical facilities all of
which facilities must be provided on its premises or under its control or
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Section 3 How to get benefits continued
b specialized inpatient medical care and treatment of sick or injured persons 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 facilities
In no event shall the term hospital include a convalescent nursing home or institution or part thereof that
1 is used principally as a convalescent facility rest facility nursing facility or facility for the aged
2 furnishes primarily domiciliary or custodial care including training in the routines of daily living or
3 is operated as a school
For inpatient and outpatient treatment of alcohol and drug abuse the term hospital also includes a free standing alcohol and drug abuse treatment
facility approved by the JCAHO
Skilled nursing An institution or that part of an institution that provides convalescent facility skilled nursing care 24 hours a day and is classified as a skilled nursing
facility under Medicare
Covered providers
Physician Doctors of medicine M D osteopathy D O dental surgery D D S medical dentistry D M D podiatric medicine D P M and optometry
O D when acting within the scope of their licenses or certification
Qualified An individual who has earned either a Doctoral or Masters Clinical Clinical Degree in psychology or an allied discipline and who is licensed or
Psychologist certified in the state where services are performed This presumes a licensed individual has demonstrated to the satisfaction of state licensing
officials that he she by virtue of academic and clinical experience is qualified to provide psychological services in that state
Nurse Midwife A person who is certified by the American College of Nurse Midwives or is licensed or certified as a nurse midwife in states requiring licensure or
certification
Nurse A person who 1 has an active R N license in the United States 2 has a Practitioner baccalaureate or higher degree in nursing and 3 is licensed or certified
Clinical Specialist as a nurse practitioner or clinical nurse specialist in states requiring licensure or certification
Clinical Social A social worker who 1 has a master's or doctoral degree in social work Worker 2 has at least two years of clinical social work practice and 3 in states
requiring licensure certification or registration is licensed certified or registered as a social worker where the services are rendered
Nursing School A clinic that is 1 licensed or certified in the state where the services are Administered performed and 2 provides ambulatory care in an outpatient setting
Clinic primarily in rural or inner city areas where there is a shortage of physicians Services billed for by these clinics are considered outpatient
office services rather than facility charges
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Section 3 How to get benefits continued
Physician A person who is licensed registered or certified in the state where Assistant services are performed
Licensed A person who is licensed registered or certified in the state where Professional services are performed
Counselor or Master's Level
Counselor
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 Underserved medical practitioner will medically be treated as a covered provider for
Areas any covered services performed within the scope of that of license For 2000 the States designated as medically underserved are Alabama
Idaho Kentucky Louisiana Mississippi Missouri New Mexico North Dakota South Dakota South Carolina Utah and Wyoming
Christian Science Charges of a Christian Science practitioner are allowable expenses if the Practitioners practitioner's services are elected instead of a doctor This election must
be made separately for each individual the first time a claim is filed each calendar year and will apply to expenses incurred during that year This
election may be changed the following year if desired The practitioner must be listed as such in the Christian Science Journal current at the time
the service is provided This election will not apply to nor prevent payment of a doctor's charges under Maternity Benefits
PPO PPO facilities agree to provide service to Plan members at a lesser cost Arrangements than for the same services from a non PPO provider Although they are
not available in all locations your use of them whenever possible helps contain health care costs and reduces your out of pocket costs The
selection of PPO providers is solely the Carrier's responsibility continued participation of any specific provider cannot be guaranteed
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
This Plan's PPO In the PPO Network Area this Plan covers two types of providers 1 those that participate in a preferred provider organization PPO and 2
those that do not
When you use a Providers who belong to the network must meet specific criteria PPO provider including location medical specialty professional skill and proper
credentials The Carrier will publish an updated list of preferred providers periodically For the most current list of preferred providers
you may contact your Plan Administrator The list will show when a preferred provider's participation in the Carrier's preferred provider
option is limited to
1 a part of a health care facility or
2 the furnishing of certain covered services
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Section 3 How to get benefits continued
Enrollees who reside in the PPO Network Area as defined below may utilize the Preferred Provider Organization network when they get local
doctor and or hospital care Subject to the Plan's definitions limitations and exclusions the Plan pays 100 of covered charges for a semi private
room and other covered hospital charges with no deductible for members who are admitted to a PPO provider facility 90 of covered charges for
surgical services of a PPO doctor and 100 for covered charges in excess of the 10 copayment for specified services of a PPO doctor other than
for surgery If you reside in Washington DC or in one of the cities or counties listed below call 800 634 0069 for information concerning the
PPO When you phone for an appointment please remember to verify that the physician is still a PPO provider
When you use a Enrollees who reside in the PPO Network Area who elect to use the non PPO services of a non PPO provider facility will be required to pay a 100 per
provider admission per person deductible if confined in a non PPO facility The Plan will then pay 75 of covered charges for a semi private room and
board rate and other hospital charges until the member's out of pocket costs equal 3,000 as defined on pages 45 46 The Plan will then pay
these charges at 100
If you elect to use the services of a non PPO doctor the Plan will pay 75 of reasonable and customary covered charges subject to the
deductible when applicable
PPO Network Alaska County of Anchorage Area California Counties Alameda Amador Butte Calaveras Colusa
Contra Costa Del Note El Dorado Fresno Glenn Humboldt Imperial Inyo Kern Kings Lake Los Angeles Madera Marin Mariposa
Mendocino Merced Mono Monterey Napa Nevada Orange Placer Plumas Riverside Sacramento San Benito San Bernadino San Diego
San Francisco San Juaquin San Luis Obispo San Mateo Santa Barbara Santa Clara Santa Cruz Shasta Solano Sonoma Stanislaus Sutter
Tehama Trinity Tulare Tuolumne Vbentura Yolo and Yuba District of Columbia
Florida Counties Brevard Broward Charlotte Citrus Collier Dade DeSoto Glades Hardee Hendry Hernando Highlands Hillsborough
Indian River Lake Lee Manatee Martin Monroe Okeechobee Orange Osceola Palm Beach Pasco Pinellas Polk Saint Lucie Sarasota
Seminole Sumter and Volusia Idaho Counties Benewah Bonner Boundary Clearwater Kootenai
Latah Lewis Nez Perce and Shoshone Maryland Counties Anne Arundel Baltimore Carroll Cecil Charles
Frederick Harford Howard Montgomery Prince Georges Queen Annes St Marys City Baltimore
Virginia Counties Accomack Albemarle Amelia Arlington Augusta Brunswick Charles City Chesterfield Culpeper Cumberland
Dinwiddie Essex Fairfax Fauquier Fluvanna Gloucester Goochland Greene Greenville Hanover Henrico Isle of Wight James City King
and Queen King William Lancaster Loudoun Louisa Lunenburg Madison Mathews Mecklenburg Middlesex Nelson New Kent North
Hampton Northumberland Nottoway Orange Powhatan Prince Edward Prince George Prince William Richmond Southampton
Spotsylvania Stafford Surry Sussex Westmoreland York Cities Alexandria Charlottesville Chesapeake Colonial Heights Emporia
Fairfax Falls Church Franklin Hampton Hopewell Manassas Newport News Norfolk Petersburg Portsmouth Richmond Suffolk Virginia
Beach Williamsburg
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Section 3 How to get benefits continued
Washington Counties Adams Asotin Benton Chelan Clallam Columbia Cowlitz Douglas Ferry Franklin Garfield Grant Grays
Harbor Island Jefferson King Kitsap Kittias Klickitat Lewis Lincoln Mason Okanogan Pacific Pend Oreille Pierce San Juan
Skagit Skamania Snohomish Spokane Stevens Thurston Wahkiakum Walla Walla Whatcom Whitman and Yakima
If you reside in this area and receive inpatient services or supplies from any non PPO hospital provider or doctor it will result in higher out ofpocket
costs to you You must utilize PPO providers to receive maximum Plan benefits
Outside the Enrollees who reside outside the PPO Network Area will be required to Network Area pay a 100 per admission per person deductible if confined in a hospital
The Plan will then pay 100 of covered hospital charges
The Plan will pay 85 of reasonable and customary covered doctor charges subject to the deductible when applicable
What do I do if First call our customer service department at 800 634 0069 If you are I'm in the hospital new to the FEHB Program we will reimburse your covered expenses If
when I join this you are currently in the FEHB Program and are switching to us your Plan 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 apply only to the person who is hospitalized
What if I have a Please contact us if you believe your condition is chronic or disabling If serious illness and it is you may be able to continue seeing your provider for up to 90 days
my provider after you receive notice that we are terminating our contract with the leaves the Plan or provider unless the termination is for cause If you are in the second or
third trimester of pregnancy you may continue to see your OB GYN until this Plan leaves the end of your postpartum care
the Program You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and you enroll in a new FEHB plan Contact
the new plan and explain that you have a serious or chronic condition or are in your second or third trimester Your new plan will pay for or
provide your care for up to 90 days after you receive notice that your prior plan is leaving the FEHB Program If you are in your second or third
trimester your new plan will pay for the OB GYN care you receive from your current provider until the end of your postpartum care
If you continue seeing your specialist or OB GYN under these conditions your cost will be no more than you would normally pay for
the services covered
How do you A drug device or biological product is experimental or investigational if decide if a service the drug device or biological product cannot be lawfully marketed
is experimental or without approval of the U S Food and Drug Administration FDA and investigational approval for marketing has not been given at the time it is furnished
Approval means all forms of acceptance by the FDA
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Section 3 How to get benefits continued
A medical treatment or procedure or a drug device or biological product is experimental or investigational if 1 reliable evidence shows
that it is the subject of ongoing phase I II or III clinical trials or under study to determine its maximum tolerated dose its toxicity its safety its
efficacy or its efficacy as compared with the standard means of treatment or diagnosis or 2 reliable evidence shows that the consensus of opinion
among experts regarding the drug device or biological product or medical treatment or procedure is that further studies or clinical trials
necessary to determine its maximum tolerated dose its toxicity its safety its efficacy or its efficacy as compared with the standard means of
treatment or diagnosis
Reliable evidence shall mean only published reports and articles in the authoritative medical and scientific literature the written protocol or
protocols used by the treating facility or the protocol s of another facility studying substantially the same drug device or 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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Section 4 What if we deny your claim or request for
pre authorization
What should I do Before you ask us to reconsider your claim you should first check with your before filing a provider or or facility to be sure that the claim was filed correctly For instance
disputed claim did the provider use the correct procedure code 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 any documentation
that supports your claim
If we deny your request for pre authorization or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer 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
3 Arrange for a health care provider to give you the service or
4 Approve your request for pre authorization
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 OPM to review a initial denial or refusal OPM will determine if we correctly applied the
denial terms of our contract when we denied your claim or request for service
What if I have a Call us 800 634 0069 and we will expedite our review serious or life
threatening condition and
you haven't responded to my
request for preauthorization
What if you have If we expedite your review due to a serious medical condition and deny denied myrequest your request we will inform OPM so that they can give your claim
for care and my expedited treatment too Alternatively you can call OPM's health condition is benefits Contract Division II at 202 606 3818 between 8 a m and 5
p m Serious or life threatening conditions are ones that may cause serious or lifethreatening permanent loss of bodily functions or death if they are not treated as soon
as possible
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Section 4 What if we deny your claim or request for
pre authorization continued
Are there other You must write to OPM and ask them to review our decision within 90 time limits days after we uphold our initial denial or refusal You may also ask OPM
to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your request within 120 days of the date you asked us
to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30 days In this case OPM must receive your
request within 120 days of the date we asked you for additional information
What do I send to Your request must be complete or OPM will return it to you You must OPM send the following information
1 A statement about why you believe our decision is wrong based on specific benefit provisions in this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills medical records and explanation of
benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to which claim
Who can make Those who have a legal right to file a disputed claim with OPM are the request
1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled person's representative They must send a
copy of the person's specific written consent with the review request
What if OPM OPM's decision is final There are no other administrative appeals If upholds the OPM agrees with our decision your only recourse is to sue If you decide
Plan's denial 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 mail my disputed of Insurance Programs Contracts Division II P O Box 436 Washington
claim to OPM DC 20044
What laws apply Federal law governs your lawsuit benefits and payment of benefits The if I file a lawsuit Federal court will base 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
17
17
17
Page 18
19
Section 4 What if we deny your claim or request for
pre authorization continued
Your records and Chapter 89 of title 5 United States Code allows OPM to use the the Privacy Act information it collects from you 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
18
18
18
Page 19
20
Section 5 Benefits
Inpatient Hospitial Benefits
What is covered The Plan pays for inpatient hospital services as shown below
Pre certification The medical necessity of your hospital admission must be pre certified for you to receive full Plan benefits Emergency admissions not precertified
must be reported within two business days following the day of admission even if you have been discharged Otherwise the benefits
payable will be reduced by 500 See pages 44 45 for details
Waiver This pre certification requirement does not apply to persons whose primary coverage is Medicare Part A another insurance policy or when
the hospital admission is outside the continental United States Alaska and Hawaii For information on when Medicare is primary see page 39
Room and board and For semiprivate room and other hospital services including intensive other charges care units the Plan pays as follows If a private room is used the patient
pays the cost in excess of the hospital's average semiprivate room rate unless the Plan determines that isolation is medically necessary If the
hospital does not have semiprivate rooms payment will be based on the average semiprivate room rate in the geographic area
PPO benefit 100 of covered charges at a PPO Network facility no deductible applies
Non PPO benefit If your permanent address is inside the PPO Network Area 75 of covered charges after the 100 deductible per hospital admission
If your permanent address is outside the PPO Network Area 100 of covered charges after the 100 deductible per hospital admission
Catastrophic The enrollee's share of covered charges at a non PPO facility will be protection covered in full when 1 that enrollee's calendar year deductible is met
and 2 applicable expenses of that enrollee and any other family members exceed the catastrophic protection limit described on pages 45 46
Out of Area At the discretion of the Plan benefits equal to those for enrollees residing Emergency outside the PPO Network Area may be applied for those individuals who
Admission reside in the PPO network area but are hospital confined for a medical emergency or accident while temporarily traveling outside the network
area The Plan at its discretion may require such insured person to be transferred to any Mutual Of Omaha participating facility when such a
facility is medically safe
Medical Emergency means the sudden and unexpected onset of a condition or injury that you believe endangers your life or could result in
serious injury or disability and requires immediate medical or surgical care that the covered person secures within 72 hours after the onset
Medical emergencies include deep cuts broken bones heart attacks cardiovascular accidents poisonings loss of acute consciousness or
respiration convulsions and such other acute conditions as may be determined by the Carrier to be medical emergencies
Limited benefits
Pre admission 100 of reasonable and customary charges for outpatient diagnostic Xray testing and laboratory tests when performed within 7 days before a scheduled
admission and that
1 are related to a covered hospital confinement
19
19
19
Page 20
21
Section 5 Benefits continued
2 are accepted by the hospital instead of tests that would have been performed during the confinement and
3 are repeated only if the patient's medical record shows the preadmission test results and the need for repeated tests upon
admission
Hospitalization for 100 for semiprivate room and other hospital charges in connection with dental work dental procedures even though the dental work itself may not be
covered only when a nondental physical impairment exists that makes hospitalization necessary to safeguard the health of the patient
Related benefits
Professional Charges for the professional services of a doctor or any other practitioner charges covered by this Plan even though billed by a hospital as part of the
hospital services are covered under Surgical Benefits or Other Medical Benefits See pages 21 22 and 26 28
Skilled nursing See Additional Benefits page 30 care
Take home items Drugs and medicines furnished upon discharge for use at home are covered only under Prescription Drug Benefits See pages 32 33 Medical
supplies furnished upon discharge for use at home are covered only under Other Medical Benefits See page 27
What is not Confinement in nursing homes rest homes places for the aged covered convalescent homes or any place that is not a hospital skilled nursing
facility or hospice See definitions on pages 10 11
Custodial care as defined on page 47 even when provided by a hospital
A hospital admission that is not medically necessary i e the medical services did not require the acute hospital inpatient overnight setting
but could have been provided in a doctor's office the outpatient department of a hospital or some other setting without adversely
affecting the patient's condition or quality of medical care rendered
Inpatient hospital services and supplies for surgery not covered by the Plan
Inpatient private duty nursing
Personal comfort services of a luxury nature such as radio television telephone beauty and barber services
20
20
20
Page 21
22
Section 5 Benefits continued
Surgical Benefits
PPO Surgical Benefits for Enrollees Residing in the Network Area
Hospital inpatient 90 of the covered charges for inpatient surgical services and procedures
Outpatient 90 of the covered charges for outpatient surgery performed at a hospital doctor's office or surgi center Directly related services and
supplies rendered at the time of the surgery are paid at 100 of the reasonable and customary charge
Charges for normal post operative care by the doctor who performed the surgery are considered part of the surgical charge
Anesthesia 90 of the covered charges based on CPT code and time
Non PPO Surgical Benefits for Those Residing in and out of the Network Area
Hospital inpatient For enrollees residing in the PPO Network Area The Plan pays 75 of the reasonable and customary charges for inpatient surgical services and
procedures
For enrollees residing outside the PPO Network Area The Plan pays 85 of the reasonable and customary charges for inpatient surgical services
and procedures
Outpatient For enrollees residing in the PPO Network Area 75 of the reasonable and customary charges for outpatient surgery performed at a hospital
doctor's office or surgicenter Directly related services and supplies rendered at the time of the surgery are paid at 100 of the reasonable and
customary charge
For enrollees residing outside the PPO Network Area 85 of the reasonable and customary charges for outpatient surgery performed at a
hospital doctor's office or surgicenter Directly related services and supplies rendered at the time of the surgery are paid at 100 of the usual
and customary charge
Anesthesia The applicable percentage of the reasonable and customary charges based on CPT and time
Multiple surgical When multiple or bilateral surgical procedures that add time or procedures complexity to patient care are performed during the same operative
session the Plan pays the value of the major procedure plus 50 of the value of the lesser procedure s at the applicable percentage rate of the
covered charges For certain surgical procedures a value of less than 50 may be applied for subsequent procedures
Incidental When an incidental procedure e g incidental appendectomy lysis of procedures adhesions excision of scar is performed through the same incision the
reasonable and customary allowance will be that of the major procedure only
Assistant surgeon Services of an assistant surgeon are payable at the applicable percentage of the covered charges based on 20 of the covered charges allocated to
the surgeon
Second opinion Covered under Other Medical Benefits See page 26 voluntary
21
21
21
Page 22
23
Section 5 Benefits continued
Organ tissue Transplant surgery means transfer of a body organ s from the donor to transplants and the recipient Donor means a person who undergoes a surgical operation
donor expenses for the purpose of donating a body organ s for transplant surgery Recipient means an insured person who undergoes a surgical operation to
receive a body organ transplant
What is covered Cornea heart kidney liver pancreas heart lung single lung and double lung transplants
Bone marrow and stem cell support as follows
Allogeneic donor bone marrow transplants
Autologous bone marrow transplants autologous stem cell support and peripheral stem cell support for acute lymphocytic or nonlymphocytic
leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma advanced neuroblastoma breast cancer
multiple myeloma epithelial ovarian cancer and testicular mediastinal retroperitoneal and ovarian germ cell tumors
Related medical and hospital expenses of the donor when the recipient is covered by the Plan Recipient means an insured person who
undergoes an operation to receive an organ transplant Donor means a person who undergoes an operation for the purpose of donating an
organ for transplant surgery
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 Transplants not listed as covered covered
Oral and 80 of the reasonable and customary charges for maxillofacial
Surgery by an oral surgeon for operations that do not involve any tooth surgery structure alveolar process abscess or disease of periodontal or
gingival tissue or dental implants
Surgical correction of temporomandibular joint TMJ dysfunction
Surgical removal of impacted teeth
What is not Cosmetic surgery as defined on page 47 except for the repair of covered accidental injuries sustained while covered under the FEHB Program
to correct congenital anomalies as defined on page 47
Radial keratotomy or similar surgery to treat myopia except for cornea graft
Removal of corns or calluses or the trimming of toenails and similar routine treatment ofconditions of the foot
Reversal of voluntary surgical sterilization
22
22
22
Page 23
24
Section 5 Benefits continued
Maternity Benefits
What is covered The Plan pays the same benefits as for hospital surgery delivery laboratory tests and other medical expenses as for illness or injury
Inpatient hospital
Pre certification The medical necessity of your hospital admission must be pre certified for you to receive full Plan benefits Unscheduled or emergency
admissions not pre certified must be reported within two business days following the day of admission even if you have been discharged
Newborn confinements that extend beyond the mother's discharge must also be pre certified If any of the above are not done the benefits payable
will be reduced by 500 See page 44 for details
Waiver See page 44 for instances when pre certification is not required
Room and board The Plan pays for semiprivate room and other hospital services as and other charges follows Bassinet or nursery charges for days on which mother and child
are both confined are considered maternity expenses of the mother and not expenses of the child
PPO Benefit If you reside in the PPO Network Area 100 of covered charges at a PPO network facility no deductible applies
Non PPO Benefit If you reside in the PPO Network Area 75 of covered charges after the 100 per admission deductible
If you reside outside the PPO Network Area 100 of covered charges after the 100 deductible per hospital admission
Outpatient Care 100 of reasonable and customary charges for covered hospital and physician services at the time of delivery no deductible when
Delivery is on an outpatient basis or
Delivery is at a licensed birthing center or
Inpatient delivery results in a hospital confinement of one day overnight or less and no more than one day's room and board charge
applies
Limitations If the mother and or newborn child is transferred from a birthing center to a hospital due to medical complications the birthing center expenses
will be paid as inpatient care
For a confinement of one day overnight or less if the mother and child leave the hospital against medical advice this outpatient maternity
benefit is not payable
Obstetrical care For a confinement of 2 or more days charges of the doctor and or State licensed midwife for delivery prenatal and postnatal visits or abortion
are paid under Surgical Benefits pages 21 22
Newborn care PPO Benefits If you reside in the PPO Network Area 90 of covered charges for the initial routine inhospital examination of a newborn
infant not subject to the calendar year deductible Routine circumcision for an infant covered under a Self and Family enrollment is covered under
Surgical Benefits
23
23
23
Page 24
25
Section 5 Benefits continued
Non PPO benefits If you reside in the PPO Network Area 75 of reasonable and customary charges for the initial routine inhospital
examination of a newborn infant not subject to the calendar year deductible Routine circumcision for an infant covered under a Self and
Family enrollment is covered under Surgical Benefits
If you reside outside the PPO Network Area 85 of reasonable and customary charges for the initial routine inhospital examination of a
newborn infant not subject to the calendar year deductible Routine circumcision for an infant covered under a Self and family enrollment is
covered under Surgical Benefits
Related benefits
Diagnosis and Services for the diagnosis and treatment of infertility are covered under treatment of Other Medical Benefits See page 28
infertility
Tests Sonograms and other related tests on the unborn are covered under Other Medical Benefits Amniocentesis is covered under Surgical Benefits
pages 21 and 22
Voluntary Covered under Surgical Benefits see page 21 sterilization
Contraceptive Contraceptive drugs and devices dispensed by a retail pharmacy or Drugs obtained through the Mail Order Program are covered as prescription
drugs see page 33
For whom Benefits are payable under Self Only enrollments and for family members covered under Self and Family enrollments
What is not Assisted Reproductive Technology ART such as artificial covered insemination in vitro fertilization embryo transfer and GIFT
Services and supplies related to ART procedures are not covered
Services received before enrollment begins or after enrollment ends
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
24
24
24
Page 25
26
Section 5 Benefits continued
Mental Conditions Substance Abuse Benefits
What is covered
Mental Conditions Inpatient Care
Pre certification The medical necessity of your admission to a hospital or other covered facility must be pre certified 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 44 for details
Waiver See page 19 for when pre certification is not required
PPO benefit 100 of covered hospital charges at a PPO Network facility no deductible applies
Non PPO benefit If you reside in the PPO Network Area 75 of covered hospital charges after the 100 deductible per admission Catastrophic protection applies
see page 45
If you reside outside the PPO Network Area after the 100 per person per admission hospital deductible 100 of covered hospital charges for
up to 60 days per confinement and 80 for the 61st day and thereafter
Inpatient and After the 250 calendar year deductible the Plan will consider charges Outpatient for psychiatric treatment sessions including group sessions up to 90
psychiatric of covered charges for PPO Providers and up to 50 treatment sessions sessions of reasonable and customary charges for Non PPO Providers for a
treatment maximum of 50 visits per person per calendar year The medical management of mental conditions will be covered under this
Plan's Other Medical Benefits provision Related drug costs will be covered under this Plan's Prescription Drug Benefits Office visits for the
medical aspects of this treatment do not count toward the 50 visits per person per year calendar maximum
Outpatient care 50 of reasonable and customary charges for treatment in a qualified day care center as determined by the Plan A qualified day care center is
one that provides a planned program of psychiatric care for patients who are at the center for only a part of each day Doctors offices facilities
operating principally as schools or recreational or training centers and facilities primarily providing custodial services will not be recognized as
qualified day care centers
Substance abuse Up to 10,500 per calendar year for a 28 day inpatient treatment program including detoxification and aftercare or up to 4,000 per year for an
outpatient treatment program and aftercare in a facility as defined on pages 10 and 11 Inpatient confinements must be pre certified by the
Plan For pre certification contact the Plan at 800 634 0069
Lifetime Coverage is limited to three treatment programs per person per lifetime maximum Withdrawal from a treatment program prior to completion constitutes use
of one program No other benefits of the Plan are payable for the treatment of substance abuse and no deductibles apply
What is not Counseling or therapy for marital educational or behavioral problems or covered related to mental retardation or learning disabilities
All charges for chemical aversion therapy conditioned reflex treatments narcotherapy or any similar aversion treatments and all related charges
including room and board
Any provider not specifically listed as covered
25
25
25
Page 26
27
Section 5 Benefits continued
Other Medical Benefits
PPO Benefits Subject to the following conditions enrollees will pay a 10 copayment for a physician's professional fee for each visit not subject to the 250
calendar year deductible nor counted toward the maximum annual out ofpocket limit
Conditions
1 No more than one copayment will be applied per day per person
2 The copayment applies to the following but is not limited to
a Services such as
1 office visits
2 consultations
3 ophthalmology exam
4 physical therapy
5 post operative follow up
6 services after hours
7 emergency office visits
b Injections including allergy injections
c Allergy testing
d Radiation therapy and
e X ray and laboratory services in the physician's office
This PPO copayment feature does not apply to all services The Plan pays 90 of covered charges subject to the 250 calendar year deductible for
the following
1 Supplies provided by the physician
2 Services ordered by the physician but billed by another provider See Other Benefits listed below
Non PPO Benefits For enrollees residing in the Network Area After the 250 calendar year deductible has been met the Plan pays 75 of the reasonable and
customary charges for services and supplies listed above to the extent they are not paid under any other benefit of the Plan
For enrollees residing outside the Network Area After the 250 calendar year deductible has been met the Plan pays 85 of reasonable and
customary charges of services and supplies listed above to the extent they are not paid under any other benefit of the Plan
Other Benefits After the 250 calendar year deductible has been met the Plan pays applicable percentages for the following services and supplies listed
below to the extent they are not paid under any other benefit of the Plan
Outpatient inpatient and out of hospital X ray and laboratory services performed by or under the supervision of a doctor See page
30 for coverage of emergency treatment of accidental injury
Doctors visits inhospital home office that are unrelated to surgery or maternity including a second surgical opinion by an independent
consulting doctor other than the surgeon
26
26
26
Page 27
28
Section 5 Benefits continued
Private duty nursing out of hospital Charges for full time nursing or visits by a Registered Nurse R N or Licensed Practical Nurse
L P N are covered only when
the care is ordered by the attending doctor and
the doctor identifies the specific professional nursing skills that the patient requires as well as the length of time needed
Services and supplies either in or out of a hospital that are recommended by the attending doctor
Orthopedic braces canes casts cervix collars cervical traction kits crutches splints and trusses
Services and for renal dialysis and chemotherapy
Two wigs per lifetime up to a maximum of 150 each and not subject to the deductible when required due to hair loss in connection with
chemo or radiation therapy
Radium radio radioactive isotopes and X ray therapy
Oxygen and rental of equipment for its administration
Local ambulance service above the 50 covered under Additional Benefits or if a special and unique hospital treatment is required that
is not available locally transportation by professional ambulance railroad or commercial airline on a regularly scheduled flight within
the United States or Canada to the nearest hospital equipped to furnish the treatment This benefit does not apply to transportation necessary
to obtain the services of a specific doctor or any other practitioner
Rental up to the purchase price at the option of the Plan or purchase of durable medical equipment including items such as wheelchairs
hospital beds respirators and other items that the Plan determines are durable medical equipment See definition on page 48 Durable
medical equipment must be preapproved by the Plan before purchase or rental in excess of 30 days
Services of a registered physical therapist or a registered occupational therapist practicing within the scope of the license for administration
of therapy in accordance with a doctor's specific instructions as to type frequency and duration
Speech therapy provided by a licensed speech therapist practicing within the scope of the license but only when necessary to restore
speech when there has been a functional loss of speech due to illness or injury and when therapy is rendered in accordance with a doctor's
specific instructions as to type and duration
Artificial eyes and limbs required to replace natural eyes and limbs
One pair of eyeglasses or contact lenses per lifetime and examination for them if required to correct an impairment directly caused by
accidental eye injury or eye surgery The services must be received within one year of the date of accident or surgery
One hearing aid and examination per lifetime if required to correct an impairment directly caused by accidental injury or intra aural surgery
The expenses must be incurred within one year of the date of the accident or surgery
27
27
27
Page 28
29
Section 5 Benefits continued
Two external breast prostheses and two bras per calendar year following mastectomy and designed exclusively for use with an
external prosthesis
Blood or blood plasma not donated or replaced and its administration
One tetanus diphtheria TD booster every 10 years for patients over 19 years of age one pneumococcal pneumonia vaccine per year for
patients age 65 years and over and one influenza flu vaccine per year per person
Limited benefits
Diagnosis and After the 250 calendar year deductible the Plan pays charges in the treatment of same manner as any other covered benefit up to 5,000 per person per
Infertility lifetime for the diagnosis and treatment of infertility as defined below
1 the initial diagnostic test and procedures done solely to identify the
cause or causes of the inability to conceive
2 hormne therapy FDA approved drugs and related services and
3 medical or surgical services performed solely to create or enhance the
ability to conceive
Smoking cessation After the 250 calendar year deductible has been met the Plan will pay benefit up to 100 for enrollment in one smoking cessation program per person
per lifetime This benefit includes FDA approved drugs and medicines that are intended to aid in smoking cessation Smoking cessation drugs
and medicines are not covered under any other Plan provisions
Well child care After the 250 calendar year deductible has been met the Plan will pay applicable percentages for all routine inhospital visits and all routine
office visits for the child's first 24 months Coverage for immunizations is described on page 30
Preventative Services
Routine Physical One annual routine physical examination per person to include a history examination and physical chest X ray urinalysis blood tests and EKG
electrocardiogram Also included are
Cervical cancer screening Annual pap smear for women age 18 and older
Prostate cancer screening Annual PSA Prostate Specific Antigen test for males age 40 and older
Colorectal cancer screening Annual fecal occult blood test for members age 40 and older and a sigmoidoscopy every 5 years starting
at age 50
Breast cancer screening Mammograms are covered for women age 35 and older as follows
From age 35 39 one baseline mammogram during this five year period
From age 40 45 one mammogram screening every other calendar year
From age 45 one mammogram every calendar year
28
28
28
Page 29
30
Section 5 Benefits continued
Benefits levels are indicated below
PPO Benefits For enrollees residing in the Network Area 10 copayment for a physician's professional fee and services provided in the physician's
office 90 of covered charges for services provided outside physician's office subject to the 250 deductible
Non PPO Benefits For enrollees residing in the Network Area 75 of reasonable and customary charges subject to the 250 deductible
For enrollees residing outside the Network Area 85 of reasonable and customary charges not subject to the 250 deductible
What is not Sun or heat lamps whirlpool baths heating pads air purifiers covered humidifiers air conditioners exercise devices and other items that do
not meet the definition of durable medical equipment
Services of a private duty nurse whose duties consist primarily of custodial care
Orthopedic shoes orthotics and other supportive devices for the feet
Provocative food testing end point titration techniques hair analysis and sublingual allergy desensitization
Preventative medical care and services including periodic checkups and immunizations such as polio flu mumps and smallpox shots
except as provided under the Routine physical exam and Childhood immunizations benefits on page 30 and under the Well child care on
page 28
Eyeglasses contact lenses or examinations for them except as specified on page 27 and eye refractions
Hearing aids or examinations for them except as specified on page 27
Weight control or any treatment of obesity except surgery for morbid obesity as defined on page 49
Services and supplies for cosmetic purposes except for wigs as described on page 27
Services of a chiropractor
Chelation therapy except for acute arsenic gold mercury or lead poisoning
Speech therapy for congenital disorders or loss impairment due to mental psychoneurotic and personality disorders
Assisted Reproductive Technology ART procedures that enable a woman with otherwise untreatable infertility to become pregnant
through any artificial conception procedures such as artificial insemination in vitro fertilization embryo transfer and GIFT
including services and supplies related to ART procedures
29
29
29
Page 30
31
Section 5 Benefits continued
Additional Benefits
Accidental injury 100 of reasonable and customary charges for outpatient hospital or outpatient doctors expenses for emergency treatment of accidental
bodily injury and associated X ray and laboratory expenses are covered if rendered within 96 hours of the injury Follow up doctors visits
incurred up to 30 days after the injury are also covered at 100 if initial treatment was received within 96 hours Prescriptions and durable
medical equipment related to the injury as well as all charges related to the accidental injury incurred 30 days or more after the accident are
payable as Other Medical Benefits
Ambulance Up to 50 for local ambulance service to and from a hospital in conjunction with either hospital inpatient or outpatient treatment when
ambulance use is due to an emergency or when prescribed by a doctor Reasonable and customary charges over 50 are covered under Other
Medical Benefits
Childhood 100 of reasonable and customary charges for childhood immunizations immunizations recommended by the American Academy of Pediatrics for covered
members under age 22 Inactivated poliovirus vaccine IVP at 2 and 4 months is recommended For the third and fourth doses either IVP or
oral poliovirus can be administered
Home health care If pre certified as defined on page 44 the Plan will pay up to 80 per visit for up to 90 home health care visits in a calendar year
If not pre certified the Plan will pay up to 40 per visit for up to 40 home health care visits in a calendar year
A home health care visit consists of one of the following
1 less than an 8 hour shift of nursing care or
2 one therapy session or
3 less than an 8 hour shift by a home health aide
The following services are covered
Nursing care provided on a part time basis less than an 8 hour shift by a registered nurse R N or licensed practical nurse L P N
Physical occupational or speech therapy provided by a licensed therapist
Home health aide services provided on a part time basis less than an 8 hour shift that
1 are performed by a home health aide under the supervision of a registered nurse R N and
2 consist mainly of medical care and therapy provided solely for the care of the patient
The above home health care services must be furnished
1 by a home health care agency or by visiting nurses when services of a home health care agency are not available
2 in accordance with a home health care plan as defined on page 49 and
3 in the patient's home
30
30
30
Page 31
32
Section 5 Benefits continued
Hospice care If pre certified as defined on page 44 the Plan pays 100 of reasonable and customary charges for covered medical expenses up to a lifetime
maximum of 7,500 for care provided by an independent hospice administration to a terminally ill patient in the final stage of illness when
a hospice care program as defined on page 49 is recommended by a doctor
If not pre certified as defined on page 44 the maximum allowable benefit is 4,500 for care as described above
This benefit does not apply to services shown as covered under any other provisions of this Plan
Skilled nursing If pre certified as defined on page 44 the Plan will pay 100 of facilities reasonable and customary charges for medically necessary inpatient
services for a maximum of 60 days when the confinement is under the supervision of a doctor
If not pre certified the Plan will pay 80 of reasonable and customary charges up to a maximum of 30 days per confinement
Skilled nursing facility benefits shown above will be restored for each new period of confinement There is a new period of confinement when
at least 60 days have elapsed since the patient was last confined in a skilled nursing facility
31
31
31
Page 32
33
Section 5 Benefits continued
Prescription Drug Benefits
What is covered You may purchase the following medications prescribed by a doctor from either a pharmacy or by mail
Drugs vitamins and minerals that by Federal law of the United States require a doctor's prescription for their purchase
Insulin
FDA approved drugs and devices requiring a doctor's prescription for the purpose of birth control
You may also purchase the following supplies that do not require a prescription by using your card
Diabetic colostomy and ostomy supplies
Needles and syringes for the administration of covered medications
What is not covered Medical supplies such as dressings and antiseptics Drugs and supplies for cosmetic purposes
Medication that does not require a prescription under Federal law even if your doctor prescribes it or a prescription is required under your
State law or for which there is a nonprescription equivalent available
Nutritional supplements and vitamins including prenatal that do not require a prescription
Drugs to aid in smoking cessation are covered only under the Smoking Cessation benefit
Fertility drugs are covered only under the Diagnosis and Treatment of Infertility benefit
From a Pharmacy Under the prescription drug card program you may obtain up to a 30 day supply of covered drugs If purchasing more than a 30 day supply on the
same day any expense exceeding that supply limit will not be covered through the pharmacy arrangement You may purchase your covered
prescription drugs and supplies by presenting your Prescription Drug Card along with your prescription to a preferred prescription drug
provider and paying the lesser of the drug cost or
copay of 12 per generic drug or brand name if a generic drug is not available
copay of 24 per brand name drug when required by your physician or if you request but your doctor does not require a brand name drug
and a generic equivalent is available
Prescription refills will be covered when no more than 25 of the day's supply remains based on your doctor's prescription
Call 800 752 0598 to locate a preferred prescription drug provider in your area
If your doctor prescribes a medication that will be taken over an extended period of time you should request two prescriptions one for immediate
use with the local preferred participating pharmacy and the other for up to a 90 day supply from the mail order program
Medicare B When Medicare Part B is the primary payer a 5 copay will be required for a generic drug or brand name when generic is not available Neither
the copay of 24 you are required to pay for the election of a brand name drug when generic is available nor the 5 copay will be reimbursed by the
Plan
32
32
32
Page 33
34
Section 5 Benefits continued
By mail If your doctor orders more than a 30 day supply of drugs or covered supplies up to a 90 day supply you may order your prescription or refill
by mail from the Plan's mail order drug program Express Scripts Inc will fill your prescription All drugs and supplies covered by the Plan are
available under this program except drugs to aid in smoking cessation and fertility drugs
Under the Plan's mail order drug program if a generic equivalent to the prescribed drug is available Express Scripts Inc will dispense the
generic equivalent instead of the brand name unless you or your doctor specifies that the brand name is required You pay the cost of the drug up
to the following copayment amounts
copay of 17 per generic or brand name if generic drug is not available
copay of 34 per brand name drug when required by your physician or if you request but your doctor does not require a brand name drug
and a generic equivalent is available
Medicare When Medicare Part B is the primary payer a 10 copay will be required for a generic drug or brand name when generic is not available Neither
the copay of 34 you are required to pay for the election of a brand name drug when generic is available nor the 10 copay will be reimbursed by
the Plan
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
Express Scripts Inc P O Box 27226
Albuquerque NM 87125 9908
Allow approximately two to three 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 and to request your first order forms you may call toll free 800 417 8173
Purchasing drugs Only prescription drugs and supplies available in the United States and when you are listed above as covered by the Plan are eligible for reimbursement when
overseas purchased in a foreign country These expenses are reimbursed at 80 after the 250 deductible has been met
Drugs from other Prescription drugs are also covered at 80 after the 250 deductible has sources been met under this Plan when they are provided to you by a doctor or
covered facility not to include a pharmacy
33
33
33
Page 34
35
Section 5 Benefits continued
Dental Benefits
What is covered The Plan pays only for the following services
Up to 39 for a routine oral examination including X rays cleaning diagnosis and preparatio of a treatment plan This is limited to two
exams per person per calendar year For the purpose of this benefit a routine oral exam X rays and cleaning includes treatment to maintain
the dental health of a patient
Up to the amounts specified below for dental fillings
One surface 12
Two surfaces 19
Three or more surfaces 24
Related benefits
Accidental dental The Plan pays 100 of outpatient hospital or outpatient doctors injury reasonable and customary charges for emergency treatment of accidental
dental injury not from biting or chewing to the jaw or sound natural teeth and associated X ray and laboratory expenses if rendered within 96
hours of injury Related follow up care received after 96 hours is not payable under this benefit See page 47 for definition of accidental injury
and page 50 for definition of sound natural tooth
Extended dental After the 250 calendar year deductible the Plan pays 80 of reasonable treatment and customary charges for dental services including initial replacement
of sound natural teeth and dental X rays as recommended by the attending doctor for repair of accidental injury to the jaw or sound natural
teeth occurring while insured under this Plan if received within 24 months from the date of the accident Member must remain covered by
the Plan until treatment is complete
Oral surgery For covered oral surgery see page 21
What is not Charges for tooth extractions dental implants preparation for covered orthodontic treatment or dentures or other dental work or surgery that
involves any tooth structure alveolar process abscess periodontal disease or disease of the gingival tissue
Dental appliances study models splints and other devices or dental services associated with the treatment of temporomandibular joint
TMJ dysfunction
Crowns and root canals
Other dental services not listed as covered
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Section 6 How to File a Claim
Claim forms If you do not receive your identification card s within 60 days after the identification effective date of your enrollment call the Carrier at 800 634 0069 to
cards and report the delay In the meantime use your copy of the SF 2809 questions 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 800 634 0069 or you may write the Carrier at Mutual of Omaha P O Box 668587 Charlotte NC
28266 You may also contact the Carrier by fax at 704 853 7911
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 Claims submitted by enrollees may be submitted on the HCFA1500 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 the enrollee
Name and address of person or firm providing the service or supply
Dates that services or supplies were furnished
Type of each service or supply and the charge
Diagnosis
Provider's tax I D number
In addition
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 must include nursing notes
Claims for rental or purchase of durable medical equipment 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 prescription drugs and medicines must include receipts that include the prescription number name of drug prescribing doctor's
name date and charge
Use the Plan's standard claim form to file dental claims Attach the dentist's itemized bill The dentist's bill must include name of the
patient dates of services itemized charges and the dentist's tax I D number To speed claim processing file dental bills separately from
other medical bills
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
Canceled checks cash register receipts or balance due statements are not acceptable
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Section 6 How to File a Claim continued
After completing a claim form and attaching proper documentation send claims to this address if not instructed otherwise by the Plan
Mutual of Omaha Charlotte Group Claims Processing Center
P O Box 668587 Charlotte NC 28266 8587
Call the center at 800 634 0069 if you have questions about your claims
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 all medical bills including those being accumulated 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
Submit claims Submit claims as they are incurred Claims should be filed within 90 days promptly after the expense was incurred for which the claim is being made but in
no event more than two years after the date the expense was incurred unless timely filing was prevented by administrative operations of
Government or legal incapacity provided the claim was submitted as soon as reasonably possible
When more Reply promptly when the Carrier requests information in connection with information is a claim If you do not respond the Carrier may delay processing or limit
needed the benefits available
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Section 7 General exclusions Things we don't cover
The exclusions in this section apply to all benefits 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 one of our covered providers 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
Expenses furnished without charge except as described on page 42 while in active military service or required for 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 Immediate relatives include 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
Procedures services drugs and supplies not specifically listed as covered and
Expenses you incurred before coverage under the Plan begins or after it ends
Benefits will not Any portion of a provider's fee or charge ordinarily due from the be paid for 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
excess charges for an annuitant age 65 or older who is not covered by Medicare Part A and or Part B see pages 39 40 doctor charges
exceeding the amount specified by the Department of Health and Human Services when benefits are payable under Medicare limiting
charge or State premium taxes however applied
Acupuncture except when used as an anesthetic agent for covered surgery
Weight control or any treatment of obesity except surgery for morbid obesity as defined on page 49
Custodial care
Educational training
Eye exercises and visual training Orthoptics
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Section 8 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Part Medicare 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 Medicate 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 800 638 6833
Coordinating The following information applies only to enrollees and covered family benefits members who are 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 the primary secondary status of this Plan and Medicare see pages 39 40
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 an FEHB plan and Medicare
This Plan is You are age 65 or over have Medicare Part A or Parts A and B and primary if employed by the Federal Government
1 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
2 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 was the patient's primary payer on the day before he or she became
eligible for Medicare Part A due to ESRD or
3 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 that you do not hold an appointment described under Rule 6 of the following Medicare is primary section
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Section 8 Limitations Rules that affect your benefits continued
Medicare is You are an annuitant age 65 or over covered by Medicare Part A or Parts primary if A and B and are not employed by the Federal Government
1 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
2 You are age 65 or over and a you are a Federal judge who retired under title 28 of the U S Code b you are a Tax Court judge who
retired under Section 7447 of title 26 of the U S Code or c you are the covered spouse of a retired judge described in a or b
above
3 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
4 You are enrolled in Part B only regardless of your employment status
5 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 Parts A and B
6 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
7 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
8 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 to 6 above
WhenMedicare is When Medicare is primary all or part of your Plan deductibles and primary coinsurance will be waived 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 coinsurance
Mental Conditions Substance Abuse Benefits If you are enrolled in Medicare Part A the Plan will waive the inpatient hospital deductible
and coinsurance If you are enrolled in Medicare Part B the Plan will waive the deductible and coinsurance for inpatient and outpatient
visits and outpatient care Benefits will be paid up to the stated Plan limits
Other Medical Benefits If you are enrolled in Part B the Plan will waive the deductible and any coinsurance or copayment for each home
and office visit physician outpatient consultation and second surgical opinion
Additional Benefits If you are enrolled in Medicare Part B the Plan will waive the coinsurance for mammograms and care in a skilled
nursing facility
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Section 8 Limitations Rules that affect your benefits continued
Dental Benefits Deductibles and coinsurance applicable to extended treatment of accidental dental injuries will be waived benefits for
other care will be paid up to the stated Plan amount
When Medicare is the primary payer this Plan will limit its payment to an amount that supplements the benefits 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 This is true whether or not Medicare benefits
are actually paid See below
If you are enrolled in Medicare you may be asked by a physician to sign a private contract agreeing that you can be billed directly 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
When you also When you are enrolled in a Medicare prepaid plan while you are a enroll in a member of this Plan you may continue to obtain benefits from this Plan
Medicare prepaid If you submit claims for services covered by this Plan that you receive plan 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 If you are covered by Medicare Part B and it is primary you should be payment and this aware that your out of pocket costs for services covered by both this
Plan 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 charges you 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 Summary Notice 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
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Section 8 Limitations Rules that affect your benefits continued
How to claim In most cases when services are covered by both Medicare and this Plan benefits Medicare is the primary payer if you are an annuitant and this Plan is the
primary payer if you are an employee
When Medicare is the primary payer your claims should first be submitted to Medicare The Carrier has contracted with most Medicare
Part B claims processors also known as carriers to receive electronic copies of your claims after Medicare has paid their benefits This means
you do not need to submit your Part B claims to the claims processor Call the Carrier at 800 634 0069 to find out if your claims are being filed
electronically If they are not you should initially submit your claims 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 MSN
Other Group When anyone has coverage with us and with another group health plan it insurance is called double coverage You must tell us if you or a family member has
coverage 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 this Plan will pay the lesser of 1 its benefits in full or 2 a reduced amount that when added to the benefits payable by the other
coverage will not exceed 100 of covered expenses When this Plan pays secondary it will only make up the difference between the primary plan's
coverage and this Plan's coverage Thus the combined payments from both plans may not equal the entire amount billed by the provider
When benefits are payable under automobile insurance including nofault 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 you may have
Remember Even if you do not file a claim with your other plan you must still tell us that you have double coverage
When others are Subrogation applies when you are sick or injured as a result of the act of responsible for omission of another person or party Subrogation means the Plan's right
injuries to recover any benefit for injuries payments made to you or your dependent by a third party's insurer because of the injury or illness
caused by a third party
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program
If both TRICARE and this Plan cover you we are the primary payer See your TRICARE Health Benefits Advisor if you have questions about
TRICARE coverage
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Section 8 Limitations Rules that affect your benefits continued
Workers We do not cover services that compensation
You need because of a workplace related disease or injury that the Office of Workers'Compensation Programs OWCP or a similar
Federal or State agency determine they must provide
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you
filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment we will provider your benefits
Medicaid We pay first if both Medicaid and this Plan cover you
Other Government We do not cover services and supplies that a local State or Federal Agencies Government agency directly or indirectly pays for
Overpayments If the Carrier determines that a member's claim has been paid in error for any reason the Carrier shall make a diligent effort to recover an
overpayment to the member from the member or if to the provider from the provider The Carrier may apply subsequent benefits otherwise
payable to the member or to a provider on behalf of the member to offset any overpayments
Limit on your The information in the following paragraph applies to you when 1 you costs if you're 65 are not covered by either Medicare Part A hospital insurance or Part B
or older and don't medical insurance or both 2 you are enrolled in this Plan as an have Medicare annuitant or as a former spouse or family member covered by the family
enrollment of an annuitant or former spouse and 3 you are not employed in a position which confers FEHB coverage
Inpatient If you are not covered by Medicare Part A are age 65 or older or become Hospital Care age 65 while receiving inpatient hospital service and you receive care in
a Medicare participating hospital the law 5 U S C 8904 b requires the Plan to base its payment on an amount equivalent to the amount Medicare
would have allowed if you had Medicare Part A This amount is called the equivalent Medicare amount After the Plan pays the law prohibits
the hospital from charging you for covered services after you have paid any deductibles coinsurance or copayments you owe under the Plan
Any coinsurance you owe will be based on the equivalent Medicare amount not the actual charge You and the Plan together are not legally
obligated to pay the hospital more than the equivalent Medicare amount
The Carrier's explanation of benefits EOB will tell you how much the hospital can charge you in addition to what the Plan paid If you are billed
more than the hospital is allowed to charge ask the hospital to reduce the bill If you have already paid more than you have to pay ask for a refund
If you cannot get a reduction or refund or are not sure how much you owe call the Plan at 800 634 0069 for assistance
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