Pages 1--46 from Untitled

Albany area Enrollment code
5L1 Self Only 5L2 Self and Family

Downstate area Enrollment code
S71 Self Only S72 Self and Family

Visit the OPM website at http www opm gov insure
and
this Plan's website at http www empirehealthcare com

An independent licensee of the Blue Cross and Blue Shield Association RI 73 33 1
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BLUE CHOICE HMO 2000
Table of Contents

Page
Introduction 1
Plain language 1
How to use this brochure 2
Section 1 Health Maintenance Organizations 3
Section 2 How we change for 2000 4
Section 3 How to get benefits 5 8
Section 4 What to do if we deny your claim or request for service 9 11
Section 5 Benefits 12 26
Section 6 General exclusions Things we don't cover 27
Section 7 Limitations Rules that affect your benefits 28 30
Section 8 FEHB facts 30 36
Inspector General Advisory Stop Healthcare Fraud 37
Summary of benefits Inside back cover
Premiums Back cover 2
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BlueChoice HMO 2000
Introduction
Empire Blue Cross and Blue Shield One World Trade Center New York New York 10048
0682

This brochure describes the benefits you can receive from Empire Blue Cross and Blue Shield
BlueChoice HMO under its contract CS 1657 with the Office of Personnel Management OPM as
authorized by the Federal Employees Health Benefits FEHB law 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

OPM negotiates benefits and premiums with each plan annually Benefit changes are effective
January 1 2000 and are shown on page 4 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 BlueChoice HMO as this Plan throughout this brochure even though in other legal
documents you will see a plan referred to as a carrier

These changes do not affect the benefits or services we provide We have rewritten this brochure only to
make it more understandable

We have not re written the Benefits section of this brochure You will find new benefits language next
year

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BlueChoice HMO 2000
How to use this brochure
This brochure has eight 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 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a
brief description of HMOs 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 services 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 You will also find information about non FEHB benefits

6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your
benefits

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

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BlueChoice HMO 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers
specific physicians hospitals and other providers that contract with us These providers coordinate
your health care services The care you receive includes preventative care such as routine office visits
physical exams well baby care and immunizations as well as treatment for illness and injury

When you receive services from our providers you will not have to submit claim forms or pay bills
However you must pay copayments and coinsurance listed in this brochure When you receive
emergency services you may have to submit claim forms

You should join an HMO because you prefer the plan's benefits not because a particular provider is
available You cannot change plans because a provider leaves our Plan We cannot guarantee that any
one physician hospital or other provider will be available and or remain under contract with us Our
providers follow generally accepted medical practice when prescribing any course of treatment

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BlueChoice HMO 2000
Section 2 How to change for 2000

Program wide To keep your premium as low as possible OPM has set a minimum copay of
changes 10 for all primary care office visits

This year you have a right to more information about this Plan care
management our networks facilities and providers

If you have a chronic or disabling condition and your provider leaves the Plan at
our request you may continue to see your specialist for up to 90 days If your
provider leaves the Plan and you are in the second or third trimester of
pregnancy you may be able to continue seeing your OB GYN until the end of
your postpartum care You have similar rights if this Plan leaves the FEHB
program See Section 3 How to get benefits for more information

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

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Changes to this Your share of the non postal premium for code 5L1 will increase by 9.8 and
Plan for code 5L2 by 11.5

Your share of the non postal premium for code S71 will increase by 64 and for
code S72 by 67.4

Blue Choice HMO has eliminated the Mid Hudson rating region Codes 5K1 and
5K2 and will no longer provide services to members who live or work in the
following New York counties Dutchess Orange Putnam Sullivan and Ulster
See page 5 for details

The Private Duty Nursing benefit has been eliminated Home health services of
nurses and health aides are covered under the Home Health benefit which
includes intravenous fluids and medications when prescribed by the Plan doctor
who will periodically review the program for continuing appropriateness and
need You pay nothing

The Prescription Drug benefit will include coverage for enteral formulas when
administered through feeding tubes for home use Modified solid food products
that are low in protein or contain modified protein are covered for treatment of
certain inherited diseases of amino acid or organic metabolism

Inpatient benefits for a mastectomy stay is covered for up to a minimum of 48
hours after the procedure and additional days as determined by the member and
her doctor

Benefits have been clarified to indicate that reconstructive surgery will include
reconstruction of the breast on which a mastectomy was performed and the
other breast to produce a symmetrical appearance in addition to coverage for
surgical bras and prostheses

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BlueChoice HMO 2000
Section 3 How to get benefits
What is this The service areas for this Plan where Plan providers and facilities are located are
Plan's service described below You must live or work in the service areas listed below to enroll in
area the Plan Benefits for care outside the service areas are limited to emergency services
as described on page 22 except for Urgent Care and Guest Membership which is
covered through the HMO Blue USA Network

The service area for this Plan includes the following
Upstate Code 5L Albany Clinton Columbia Delaware Essex Fulton Greene
Montgomery Rennselaer Saratoga Schenectady Schoharie Warren and Washington

Downstate S7 Bronx Kings Nassau New York Manhattan Queens Richmond
Rockland Suffolk and Westchester

The Plan offers its members expanded out of area coverage at participating Blue Cross
and Blue Shield Association BCBSA HMOs nationwide at no extra cost through
the HMO Blue USA network If you need care when you are outside the service area
call 1 800 4 HMO USA for information on the BCBSA HMO nearest you

If you or a covered family member move outside of our service area you can enroll in
another approved plan If your dependents live out of the area for example if your
child goes to college in another state you should consider enrolling in a fee for service
plan or an HMO that has agreements with affiliates in other areas If you or a family
member move you do not have to wait until Open Season to change plans Contact
your employing or retirement office

How much do I You must share the cost of some services This is called either a copayment a set
pay for dollar amount or coinsurance a set percentage of charges Please remember you
services must pay this amount when you receive services

Your out of pocket expenses for benefits under this Plan are limited to the stated
copayments required for a few benefits

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Do I have to You normally won't have to submit claims to us unless you receive emergency services
submit from a provider who doesn't contract with us If you file a claim please send us all of
claims the documents for your claim as soon as possible You must submit claims by
December 31 of the year after the year you received the service Either OPM or we
can extend this deadline if you show that circumstances beyond your control
prevented you from filing on time

Who provides BlueChoice HMO is a Mixed Model Prepayment MMP plan This means that all
my health medical care is provided by doctors practicing in their own offices or in multispecialty
care medical groups located throughout 28 counties in Eastern New York State

The BlueChoice HMO Select provider network contracts with more than 31376
leading doctors primary care and specialty care who represent a wide range of
primary and specialty categories BlueChoice HMO has more than 7677 primary care
doctors and 110 hospitals in the BlueChoice HMO Select provider network

What do I do if Call us We will help you select a new one
my primary
care physician
leaves the
Plan

What do I do if Talk to your Plan physician If you need to be hospitalized your primary care
I need to go physician or authorized specialist will make the necessary hospital arrangements and
into the supervise your care
hospital

What do I do if First call our customer service department at 1 800 453 0113 If you are new to the
I'm in the FEHB Program we will arrange for you to receive care If you are currently in the
hospital when FEHB Program and are switching to us your former plan will pay for the hospital
I join this stay until
Plan
You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first

These provisions only apply to the person who is hospitalized

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How do I get Your primary care physician will arrange your referral to a specialist
specialty care
If you need to see a specialist frequently because of a chronic complex or serious
medical condition your primary care physician will develop a treatment plan that
allows you to see your specialist for a certain number of visits without additional
referrals Your primary care physician will use our criteria when creating your
treatment plan

What do I do if Your primary care physician will decide what treatment you need If they decide to
I am seeing a refer you to a specialist ask if you can see your current specialist You must receive
specialist a written referral from your primary care doctor before seeing any other doctor
when or obtaining special services with the following exceptions a woman may see her
I enroll OB GYN and members may receive mental conditions and substance abuse services at
anytime without the need for a referral Referral to participating specialist is given at
the primary care doctor's discretion if non Plan specialists or consultants are required
the primary care doctor will arrange appropriate referrals

What do I do if Call your primary care physician who will arrange for you to see another specialist
my specialist You may receive services from your current specialist until we can make arrangements
leaves the for you to see someone else
Plan

But what if I Please contact us if you believe your condition is chronic or disabling You may be able
have a serious to continue seeing your provider for up to 90 days after we notify you that we are
illness and my terminating our contract with the provider unless the termination is for cause If you
provider leaves are in the second or third trimester of pregnancy you may continue to see your
the Plan or OB GYN until the end of your postpartum care After that the member must choose
this Plan a network provider
leaves the
Program You may also be able to continue seeing your provider if your plan drops out of the
FEHB Program and you enroll in a new FEHB plan Contact the new plan and explain
that you have a serious or chronic condition or are in 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

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How do you Your physician must get our approval before sending you to a hospital referring you
authorize to a specialist or recommending follow up care Before giving approval we consider
medical if the service is medically necessary and if it follows generally accepted medical
services practice

How do you The Plan will not cover any treatment procedure drug biological product or medical
decide if a device hereinafter technology or any hospitalization in connection with such
service is technology if in our sole discretion it is not medically necessary in that such
experimental technology is experimental or investigational Experimental or investigational means
or that the technology is
investigational
Not of proven benefit for the particular diagnosis or treatment or your particular
condition or

Not generally recognized by the medical community as reflected in the published peerreviewed
medical literature as effective or appropriate for the particular diagnosis or
treatment of your particular condition

This exclusion does not apply to cancer drugs as required by section 4303 g of the
New York State Insurance Law

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BlueChoice HMO 2000
Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request
must

1 Be in writing
2 Refer to specific brochure wording 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 Ask for more information

If we ask your medical provider for more information we will send you a copy of our request We
must make a decision within 30 days after we receive the additional information If we do not receive
the requested information within 60 days we will make our decision based on the information we
already have

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

What if I have a Call us at 1 800 453 0113 and we will expedite your review
serious or life
threatening
condition and you
haven't responded
to my request for
service

What if you have If we expedite your review due to a serious medical condition and deny your
denied my request claim we will inform OPM so that they can give your claim expedited treatment
for care and my too Alternately you can call OPM's health benefits Contract Division IV at
condition is 202 606 0737 between 8 a m and 5 p m Serious or life threatening conditions
serious or life are ones that may cause permanent loss of bodily functions or death if they are
threatening not treated as soon as possible

Are there other You must write to OPM and ask them to review our decision within 90 days
time limits after we uphold our initial denial or refusal of service 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

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What do I send to Your request must be complete or OPM will return it to you You must send
OPM 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 the Those who have a legal right to file a disputed claim with OPM are
request
1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting
as the enrolled person's representative They must send a copy of the
person's specific written consent with the review request

What address Send your request for review to Office of Personnel Management Office of
should I send my Insurance Programs Contracts Division IV P O Box 436 Washington D C
disputed claim to 20044

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

What laws apply if Federal law governs your lawsuit benefits and payment of benefits The
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

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

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BlueChoice HMO 2000
Section 5 Benefits
Medical and Surgical Benefits
What is Covered A comprehensive range of preventive diagnostic and treatment services is
provided by Plan doctors and other Plan providers This includes all necessary
office visits you pay a 10 office copay but no additional copay for laboratory
tests and x rays Within the service area house calls will be provided if in the
judgment of the Plan doctor such care is necessary and appropriate you pay a
10 copay for a doctor's house call and nothing for home visits by nurses and
health aides

The following services are included and are subject to the office visit copay
unless stated otherwise

Preventive care including well child care up to age 19 you pay nothing and periodic check ups

Mammograms are covered as follows for women age 35 or over one mammogram every year In addition to routine screening mammograms are
covered when prescribed by the doctor as medically necessary to diagnose or
treat you illness

Routine immunizations and boosters you pay nothing
Consultations by specialists
Diagnostic procedures such as laboratory tests and x rays
Self referral for routine obstetrical and gynecological care
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing and treatment materials such as allergy serum you pay nothing for allergy treatment visits you pay a 10
copay for allergy testing visits

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor Copays are waived
for maternity care and well baby care Inpatient care by the mother and her
newborn is covered for at least 48 hours after a regular delivery and 96 hours
after a cesarean delivery unless the mother elects to be discharged earlier
Inpatient stays will be extended if medically necessary If enrollment in the
Plan is terminated during pregnancy benefits will not be provided after
coverage under the Plan has ended Ordinary nursery care of the newborn
child during the covered portion of the mother's hospital confinement for
maternity will be covered under either a Self Only or Self and Family
enrollment other care of an infant who requires definitive treatment will be
covered only if the infant is covered under a Self and Family enrollment

Voluntary sterilization and family planning services
The insertion of internal prosthetic devices such as pacemakers and artificial joints

Heart heart lung kidney liver lung single and double pancreas and corneal transplants allogeneic donor bone marrow transplants autologous bone
marrow transplants autologous stem cell and peripheral stem cell support
for the following conditions acute lymphocytic or non 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 are covered
when the recipient is covered by the Plan Transplants are covered when
approved by the Plan's Medical Director

Women who undergo mastectomies may at their option have this procedure performed on an inpatient basis and remain in the hospital for a minimum of
48 hours after the procedure and additional days as determined by the
member and her doctor

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Dialysis
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity
Orthopedic devices such as braces foot orthotics except symptomatic complaints of the feet

Prosthetic devices such as breast prostheses surgical bras and artificial limbs and lenses following cataract removal
Durable medical equipment such as wheelchairs and hospital beds
Home health services of nurses and health aides including intravenous fluids and medications when prescribed by your Plan doctor who will periodically
review the program for continuing appropriateness and need

All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers at no additional cost to you

Equipment services supplies and self management education for the treatment of diabetes which have been recommended or prescribed by the
member's primary care physician or referred specialist and provided by a
certified diabetes nurse educator certified nutritionist certified dietitian or
registered dietitian This includes blood glucose monitors as well as
monitors for the legally blind testing strips for glucose monitors including
visual reading and urine testing strips data management systems insulin
syringes injection aids cartridges for the legally blind insulin pumps and
appurtenances and insulin infusion devices and oral agents for controlling
blood sugar diabetes self management education and diet information
provided by a physician certified nurse practitioner or their staff during an
office or home visit or provided in a group You pay nothing

Medical supplies such as surgical dressings splints and ostomy supplies you pay nothing

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Limited Benefits Oral and maxillofacial surgery is provided for non dental surgical and
hospitalization procedures for congenital defects such as cleft lip and cleft
palate and for medical or surgical procedures occurring within or adjacent to the
oral cavity or sinuses including but not limited to treatment of fractures and
excision of tumors and cysts All other procedures involving teeth or intra oral
areas surrounding the teeth are not covered including any dental care involved in
treatment of temporomandibular joint TMJ pain dysfunction syndrome

Reconstructive surgery is provided to correct a condition resulting from a
functional defect or from an injury or surgery that has produced a major effect on
the member's appearance and if the condition can reasonably be expected to be
corrected by such surgery A patient and her attending physician may decide
whether to have breast reconstruction surgery following a mastectomy and
whether surgery on the other breast is needed to produce a symmetrical
appearance

Short term rehabilitative therapy physical speech and occupational is
provided on an inpatient or outpatient basis for up to 60 days per condition if
significant improvement can be expected within two months you pay a 10
copay per outpatient session Speech therapy is limited to treatment of certain
speech impairments of organic origin Occupational therapy is limited to
services that assist the member to achieve and maintain self care and improved
functioning in other activities of daily living

Diagnosis and treatment of infertility is covered you pay nothing Artificial
insemination is covered you pay nothing The following types of artificial
insemination are covered Intracervical insemination and Intrauterine insemination
Cost of donor sperm is not covered Fertility drugs are not covered except for
clomiphene tablets and pergonal and metrodin injectables you pay a 10 copay
Other assisted reproductive technology ART procedures such as in vitro
fertilization and embryo transfer are not covered

Cardiac rehabilitation following a heart transplant bypass surgery or a
myocardial infarction is covered up to 36 sessions usually 3 sessions in a week
in a single 12 week period you pay nothing

Chiropractic services are covered when needed in connection with the detection
and correction of structural imbalance distortion or subluxation and for the
purposes of removing nerve interference and the effects thereof You pay a 10
copay per visit

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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What is not Physical examinations that are not necessary for medical reasons such as
covered those required for obtaining or continuing employment or insurance
attending school or camp or travel

Reversal of voluntary surgical induced sterility
Surgery primarily for cosmetic purposes
Hearing aids
Homemaker services
Long term rehabilitative therapy

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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BlueChoice HMO 2000
Hospital Extended Care Benefits
What is covered
Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit
when you are hospitalized under the care of a Plan doctor You pay nothing
All necessary services are covered including

Semiprivate room accommodations when a Plan doctor determines it is medically necessary the doctor may prescribe private accommodations or
private duty nursing care

Specialized care units such a intensive care or cardiac care unit
The length of a hospital stay following a lymph node dissection lumpectomy or mastectomy for the treatment of breast cancer will be
determined by you and your doctor However Medical Management must
precertify the actual hospital admission Your PCP or other network
physician is responsible for precertification arrangement

Extended care The Plan provides a comprehensive range of benefits for up to 60 days per
calendar year when full time skilled nursing care is necessary and confinement in
a skilled nursing facility is medically appropriate as determined by a Plan doctor
and approved by the Plan You pay nothing All necessary services are covered
including

Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan doctor

Hospice care Supportive and palliative care for a terminally ill member is covered in a hospice
facility for up to 210 days per lifetime Services include inpatient and outpatient
care and family counseling these services are provided under the direction of a
Plan doctor who certifies that the patient is in the terminal stages of illness with
a life expectancy of approximately six months or less

Ambulance Benefits are provided for ambulance transportation ordered or authorized by a
service Plan doctor

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor
procedures determines there is a need for hospitalization for reasons totally unrelated to the
dental procedure the Plan will cover the hospitalization but not the cost of the
professional dental services Conditions for which hospitalization would be
covered include hemophilia and heart disease the need for anesthesia by itself is
not such a condition

Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency
detoxification care diagnosis treatment of medical conditions and medical management of
withdrawal systems acute detoxification if the Plan doctor determines that
outpatient management is not medically appropriate See page 20 for nonmedical
substance abuse benefits

What is not Personal comfort items such as telephones and television
covered

Custodial care rest cures domiciliary or convalescent care

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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BlueChoice HMO 2000
Emergency Benefits

What is a medical A medical emergency is the sudden and unexpected onset of a condition or an
emergency injury that you believe endangers your life or could result in serious injury or
disability and requires immediate medical or surgical care Some problems are
emergencies because if not treated promptly they might become more serious
examples include deep cuts and broken bonds Others are emergencies because
they are potentially life threatening such as heart attacks strokes poisonings
gunshot wounds or sudden inability to breathe An emergency can manifest
itself by symptoms of sufficient severity including severe pain that a prudent
layperson possessing an average knowledge of medicine and health could
reasonably expect the absence of immediate medical attention to result in
placing the health of the person afflicted with such condition in serious jeopardy
serious impairment to such person's bodily functions serious dysfunction of
any bodily organ or part of such person or serious disfigurement of such person
There are many other acute conditions that the Plan may determine are medical
emergencies what they all have in common is the need for quick action

Emergencies If you are in an emergency situation please call your primary care doctor In
within the service extreme emergencies if you are unable to contact your doctor contact the local
area emergency system e g the 911 telephone system or go to the nearest hospital
emergency room Be sure to tell the emergency room personnel that you are a
Plan member so they can notify the primary care doctor or the Plan You or a
family member should notify the primary care doctor or the Plan within 24
hours It is your responsibility to ensure that the Plan has been timely notified

Plan pays Reasonable charges for emergency services to the extent the services would have
been covered if received from Plan providers

You pay 35 per hospital emergency room visit or urgent care center visit for emergency
services that are covered benefits of this Plan If the emergency results in
admission to a hospital within 24 hours the copay is waived

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Emergencies If you need to be hospitalized the Plan must be notified within 24 hours or on
outside the service the first working day following your admission unless it was not reasonably
area possible to notify the Plan within that time If a Plan doctor believes care can be
better provided in a Plan hospital you will be transferred when medically
feasible with an ambulance charges covered in full

Plan pays Reasonable charges for emergency services to the extent the services would have
been covered if received from Plan providers

You pay 35 per hospital emergency room visit or urgent care center visit for emergency
services that are covered benefits of the Plan If the emergency results in
admission to a hospital within 24 hours the copay is waived

What is covered Emergency care at a doctor's office or an urgent care center

Emergency care as an outpatient or inpatient at a hospital including doctor's services

Ambulance service approved by the Plan
Urgent care outside the service area when referred to an HMO Blue USA Network HMO

What is not Elective care or non emergency care
covered

Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

Medical and hospital costs resulting from a normal full term delivery of a baby outside the service area
Filing claims for With your authorization the Plan will pay benefits directly to the providers of
non Plan providers your emergency care upon receipt of their claims Physician claims should be

submitted on the HCFA 1500 claim form If you are required to pay for the
services submit itemized bills and your receipts to the Plan along with an
explanation of the services and the identification information from your ID card

Payment will be sent to you or the provider if you did not pay the bill unless
the claim is denied If it is denied you will receive notice of the decision
including the reasons for the denial and the provisions of the contract on which
denial was based If you disagree with the Plan's decision you may request
reconsideration in accordance with the disputed claims procedure described on
pages 9 11

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BlueChoice HMO 2000
Mental Conditions Substance Abuse

Mental Conditions
What is covered To the extent shown below the Plan provides the following services necessary
for the diagnosis and treatment of acute psychiatric conditions including the
treatment of mental illness or disorders Coverage will only be provided when
you are referred for care by the Plan's mental health care manager A written
referral in advance can be obtained by calling 1 800 635 6626 24 hours a day
7 days a week or by calling or visiting your primary care doctor Your primary
care doctor will coordinate your referral with the mental health care manager

Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services

Outpatient care Up to 60 visits to Plan doctors consultants or other psychiatric personnel each
calendar year you pay a 5 copay for each covered visit all charges thereafter

Inpatient care Up to 60 days of hospitalization each calendar year less 1 day for each 2 days
of day or night care received during the calendar year You pay nothing for the
first 60 days all charges thereafter

What is not Care for psychiatric conditions that in the professional judgment of Plan
covered doctors are not subject to significant improvement through relatively shortterm

treatment

Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless determined by a Plan doctor to be necessary and
appropriate

Psychological testing that is not medically necessary to determine the appropriate treatment of a short term psychiatric condition

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
23 25
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Substance Abuse
What is covered
This Plan provides medical and hospital services such as acute detoxification
services for the medical non psychiatric aspects of substance abuse including
alcoholism and drug addiction the same as for any other illness or condition and
to the extent shown below the services necessary for diagnosis and treatment
Coverage will only be provided when you are referred for care by the Plan's
mental health care manager A written referral in advance can be obtained by
calling 1 800 635 6626 24 hours a day seven days a week or by calling or
visiting your primary care doctor Your primary care doctor will coordinate
your referral with the mental health care manager
Outpatient care
Up to 60 outpatient visits for the treatment of either alcoholism and drug abuse
to Plan providers each calendar year you pay nothing for each covered visit all
charges thereafter Up to 20 visits may be used for family counseling
Inpatient care
Up to 30 days per calendar year in a substance abuse rehabilitation intermediate
care program in an alcohol or drug rehabilitation center approved by the Plan
you pay nothing during the benefit period all charges thereafter
What is not
covered Treatment that is not authorized by a Plan doctor

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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BlueChoice HMO 2000
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan
pharmacy will be dispensed for up to a 30 day supply You pay a 5 copay per
prescription unit or refill for up to a 30 day supply or 90 unit supply
whichever is greater for chronic drugs Mail order prescription service is
available for maintenance medications chronic drugs and contraceptives for up
to a 90 consecutive day supply A chronic drug is a drug which is an
antiarthritic an anticoagulant a cardiac drug a hormone or a thyroid
preparation

You pay a 5 copay per prescription unit or refill for generic drugs or for name
brand drugs when generic substitution is not permissible When generic
substitution is permissible i e a generic drug is available and the prescribing
doctor does not require the use of a name brand drug but you request the name
brand drug you pay the price difference between the generic and name brand
drug as well as the 5 copay per prescription unit or refill

Empire Pharmacy Management covers drugs listed on the Plan's drug formulary
A formulary is the preferred list of drugs covered by a prescription drug plan It
includes generic alternatives to more expensive brand name drugs as well as
covered brand name drugs for which there may or may not be an available generic
alternative If a physician prescribes a drug that is not on the formulary but is
medically necessary you your physician or your PCP may call Empire
Pharmacy Management at 1 800 839 8442 and present a case for an exception
Otherwise non formulary drugs as well as over the counter OTC drugs even
when prescribed by a doctor are not covered Please note that Empire regularly
reviews this list of drugs and may adjust it

Non formulary drugs will be covered when prescribed by a Plan doctor It is the
Plan doctor's responsibility to obtain authorization for non formulary drugs
before they are dispensed

Covered medications and accessories include
Drugs for which a prescription is required by law
Injectables self administered including insulin and allergy serum a copay charge applies to each vial

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
25 27
27 Page 28 29
Enteral formulas is covered only when clearly medically necessary and proven effective for individuals who are or will become malnourished or
suffer from illnesses which if left untreated cause chronic disability mental
retardation or death A legally authorized provider such as a physician must
issue a written prescription for the enteral formula attesting to its medical
necessity and proven effectiveness Modified sold food products that are
low in protein or contain modified protein are covered when medically
necessary for treatment of certain inherited diseases of amino acid or organic
acid metabolism Annual limits may apply Self prescribed supplements
routine infant bottle formulas or over the counter food supplements are not
covered

Diabetic supplies including insulin syringes needles glucose test tablets and test tape glucose monitors and test strips Benedict's solution or equivalent
and acetone test tablets covered under Medical and Surgical Benefits

Oral contraceptive drugs and diaphragms
IUD's
Clomiphene tablets pergonal and metrodin injectables
Disposable needles and syringes needed to inject covered prescribed medication

Intravenous fluids and medication for home use covered implantable drugs such as Norplant and injectable drugs such as Depo Provera are covered
under Medical and Surgical Benefits

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
26 28
28 Page 29 30
What is not Drugs available without a prescription or for which there is a nonprescription
covered equivalent available

Drugs obtained at a non Plan pharmacy except for out of area emergencies
Vitamins and nutritional substances that can be purchased without a prescription except where mandated by law

Fertility drugs except clomiphene tablets pergonal and metrodininjectables
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Smoking cessation drugs and medication except Nicorette gum for a 90 consecutive day supply of nicotine transdermal patches only once in a
lifetime

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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BlueChoice HMO 2000
Dental Benefits
Dental Care Benefits
Accidental injury Restorative services and supplies necessary to promptly repair but not replace
sound natural teeth The need for these services must result from an accidental
injury occurring while the member is covered under the FEHB Program and the
care must be performed within 12 months of the accident You pay nothing

What is not Other dental services not shown as covered
covered

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB program but are made available to all enrollees and family members of this Plan The cost of the benefits described on this page is not
included in the FEHB premium and any charges for these services do not count toward any FEHB deductibles or out ofpocket maximums These benefits are

System Analysis Review and Assistance SARA The System Analysis Review and Assistance Program or SARA is a feature of Empire's Early Risk Management program
Using a specialized computer program SARA analyzes existing medical lab pharmacy and hospital claims data to identify patients at risk for potentially serious medical conditions

If SARA identifies a potential problem an Empire Medicare Director who is a physician consults with specialist from leading academic medical centers to review the information The Empire Medical Director discusses the results with the
patient's treating physician to offer suggestions about the best course of treatment Empire may also provide the physician with the latest educational and reference material if appropriate While treatment decisions remain the responsibility of the
treating physician and member this program gives our members access to an extra level of medical expertise As always the confidentiality of members medical information is carefully protected at every step of the process

Members of any of their eligible dependents who do not want to participate in SAR much notify Empire in writing at the following address SARA Empire Blue Cross and Blue Shield PO Box 3560 Church Street Station NY NY 10008
3560 Be sure to include your Empire Blue Cross and Blue Shield ID number and the names and dates of birth of any dependents

Empire HealthLine This service offers free healthcare information 24 hours a day seven days a week to BlueChoice HMO members Call 1 877
TALK2RN 1 877 825 5276 toll free to speak with a trained registered nurse about a health concern Empire HealthLine also offers access to more than 1,100 audio tapes with the latest health information

Empire BabyCare Empire BabyCare is our comprehensive maternity management program designed to promote health pregnancies and low cost
deliveries Our program works in conjunctions with expectant mothers and their doctors to offer educational materials and other services that support the prenatal care plan The program offers comprehensive interviews to identify potential highrisk
pregnancies and if appropriate access to a network of physicians specially trained to deal with complicated pregnancies
Away From Home Care With HMO Blue USA if you and your family are traveling or are away from home for an extended period of time and need
medical care you can receive the same quality benefits you enjoy from your HMO at home through the Urgent Care and Guest Membership programs Just call our toll free number and an Away From Home Care Coordinator will put you in
touch with a qualified physician you can trust in virtually every state across the country
MBC Empire MBC Empire our behavioral health care management program offers you and your family personal confidential mental
health and substance abuse services 24 hours a day 365 days a year Whether you need help with day to day problems or more serious concerns MBC Empire gives you toll free access to specially trained patient care coordinators who will refer
you to an appropriate provider or program
BENEFITS ON THIS PAGE ARE NOT A PART OF THE FEHB CONTRACT

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BLUE CHOICE HMO 2000
Section 6 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 your Plan doctor determines it is medically necessary to prevent diagnose or
treat your illness or condition

We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits
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
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan

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BlueChoice HMO 2000
Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will
determine who is responsible for paying for medical services and we will coordinate
the payments On occasion you may need to file a Medicare claim form

If you are eligible for Medicare you may enroll in a Medicare Choice plan and also
remain enrolled with us

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

If you involuntarily lose coverage or move out of the Medicare Choice service area
you may re enroll in the FEHB Program at any time

If you do not have Medicare Part A or B you can still be covered under the FEHB
Program and your benefits will not be reduced We cannot require you to enroll in
Medicare

For information on Medicare Choice plans contact your local Social Security
Administration SSA office or request it from SSA at 1 800 638 6833 For
information on the Medicare Choice plan offered by this Plan see page 26

31 33
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Other group When anyone has coverage with us and with another group health plan it is called
insurance double coverage You must tell us if you or a family member has double coverage
coverage You must also send us documents about other insurance if we ask for them

When you have double coverage one plan is the primary payer it pays benefits first
The other plan is secondary it pays benefits next We decide which insurance is
primary according to the National Association of Insurance Commissioners
Guidelines

If we pay second we will determine what the reasonable charge for the benefit should
be After the first plan pays we will pay either what is left of the reasonable charge
or our regular benefit whichever is less We will not pay more than the reasonable
charge If we are the secondary payer we may be entitled to receive payment from
your primary plan

We will always provide you with the benefits described in this brochure Remember
even if you do not file a claim with your other plan you must still tell us that you
have double coverage

Circumstances Under certain extraordinary circumstances we may have to delay your services or be
unable to provide them In that case we will make all reasonable efforts to provide
beyond our you with necessary care
control

When others When you receive money to compensate you for medical or hospital care for injuries
are or illness that another person caused you must reimburse us for whatever services we
responsible paid for We will cover the cost of treatment that exceeds the amount you received in
for injuries the settlement If you do not seek damages you must agree to let us try This is
called subrogation If you need more information contact us for our subrogation
procedures

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

32 34
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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 provide your benefits

Medicaid We pay first if both Medicaid and this Plan cover you
Other We do not cover services and supplies that a local State or Federal Government
Government agency directly or indirectly pays for
Agencies

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BlueChoice HMO 2000
Section 8 FEHB FACTS
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights
information about which gives you the right to information about your health plan its networks
your HMO providers and facilities You can also find out about care management which
includes medical practice guidelines disease management programs and how we
determine if procedures are experimental or investigational OPM's website
www opm gov lists the specific types of information that we must make
available to you

If you want specific information about us call 1 800 453 0113 or write to
Empire Blue Cross and Blue Shield P O Box 11806 Albany New York 12211
You may also contact us by fax at 518 367 5455 or visit our website at
http www empirehealthcare com

Where do I get Your employing or retirement office can answer your questions and give you a
information about Guide to Federal Employees Health Benefits Plans brochures for other plans
enrolling in the and other materials you need to make an informed decision about
FEHB Program
When you may change your enrollment
How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter military service or retire

When your enrollment ends and
The next Open Season for enrollment

We don't determine who is eligible for coverage and in most cases cannot change
your enrollment status without information from your employing or retirement
office

When are my The benefits in this brochure are effective on January 1 If you are new to this
benefits and plan your coverage and premiums begin on the first day of your first pay period
premiums that starts on or after January 1 Annuitants premiums begin January 1
effective

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What happens When you retire you can usually stay in the FEHB Program Generally you
when I retire must have been enrolled in the FEHB Program for the last five years of your
Federal service If you do not meet this requirement you may be eligible for
other forms of coverage such as Temporary Continuation of Coverage which is
described later in this section

What types of Self Only coverage is for you alone Self and Family coverage is for you your
coverage are spouse and your unmarried dependent children under age 22 including any
available for me foster or step children your employing or retirement office authorizes coverage
and my family for Under certain circumstances you may also get coverage for a disabled child
22 years of age or older who is incapable of self support

If you have a Self Only enrollment you may change to a Self and Family
enrollment if you marry gives birth or adds a child to your family You may
change your enrollment 31 days before to 60 days after you give birth or add the
child to your family The benefits and premiums for your Self and Family
enrollment begin on the first day of the pay period in which the child is born or
becomes an eligible family member

Your employing or retirement office will not notify you when a family member
is no longer eligible to receive health benefits nor will we Please tell us
immediately when you add or remove family members from your coverage for
any reason including divorce

If you or one of your family members is enrolled in one FEHB plan that person
may not be enrolled in another FEHB plan

35 37
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Are my medical and We will keep your medical and claims information confidential Only the
claims records following will have access to it
confidential
OPM this Plan and subcontractors when they administer this contract
This plan and appropriate third parties such as other insurance plans and the Office of Workers Compensation Programs OWCP when coordinating

benefit payments and subrogating claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions

OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your identity or

OPM when reviewing a disputed claim or defending litigation about a claim

36 38
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Information for new members
Identification We will send you an Identification ID card Use your copy of the Health
cards Benefits Election Form SF 2809 or the OPM annuitant confirmation letter until
you receive your ID card You can also use an Employee Express confirmation
letter

What if I paid a Your old plan's deductible continues until our coverage begins
deductible under
my old plan

Pre existing We will not refuse to cover the treatment of a condition that you or a family
conditions member had before you enrolled in this Plan solely because you had the
condition before you enrolled

When you lose benefits
What happens if You will receive an additional 31 days of coverage for no additional premium
my enrollment when
in this Plan
ends Your enrollment ends unless you cancel your enrollment or

You are a family member no longer eligible for coverage

You may be eligible for former spouse coverage or Temporary Continuation of
Coverage

What is former If you are divorced from a Federal employee or annuitant you may not continue
spouse to get benefits under your former spouse's enrollment But you may be eligible
coverage for your own FEHB coverage under the spouse equity law If you are recently
divorced or are anticipating a divorce contact your ex spouse's employing or
retirement office to get more information about your coverage choices

37 39
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What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or
if you lose coverage because you no longer qualify as a family member you may
be eligible for TCC For example you can receive TCC if you are not able to
continue your FEHB enrollment after you retire You may not elect TCC if you
are fired from your Federal job due to gross misconduct

Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal
Employees Health Benefits Plans for Temporary Continuation of Coverage and
Former Spouse Enrollees from your employing or retirement office

Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate

If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32 nd day after your regular coverage ends even if

several months have passed
You pay the total premium and generally a 2 percent administrative charge The government does not share your costs

You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits

38 40
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How do I enroll If you leave Federal service your employing office will notify you of your right
in TCC to enroll under TCC You must enroll within 60 days of leaving or receiving this
notice whichever is later

Children You must notify your employing or retirement office within 60
days after your child is no longer an eligible family member That office will
send you information about enrolling in TCC You must enroll your child
within 60 days after they become eligible for TCC or receive this notice
whichever is later

Former spouses You or your former spouse must notify your employing or
retirement office within 60 days of one of these qualifying events

Divorce
Loss of spouse equity coverage within 36 months after the divorce

Your employing or retirement office will then send your former spouse
information about enrolling in TCC Your former spouse must enroll within
60 days after the event which qualifies them for coverage or receiving the
information whichever is later

Note Your child or former spouse loses TCC eligibility unless you or your
former spouse notifies your employing or retirement office within the 60 day
deadline

39 41
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How can I You may convert to an individual policy if
convert to
individual Your coverage under TCC or the spouse equity law ends If you canceled
coverage your coverage or did not pay your premium you cannot convert

You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law

If you leave Federal service your employing office will notify you if individual
coverage is available You must apply in writing to us within 31 days after you
receive this notice However if you are a family member who is losing coverage
the employing or retirement office will not notify you You must apply in
writing to us within 31 days after you are no longer eligible for coverage

Your benefits and rates will differ from those under the FEHB Program
however you will not have to answer questions about your health and we will
not impose a waiting period or limit your coverage due to pre existing
conditions

How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health
Certificate of Plan Coverage that indicates how long you have been enrolled with us You can
Group Health use this certificate when getting health insurance or other health care coverage
Plan Coverage You must arrange for the other coverage within 63 days of leaving this Plan
Your new plan must reduce or eliminate waiting periods limitations or
exclusions for health related conditions based on the information in the
certificate

If you have been enrolled with us for less than 12 months but were previously
enrolled in other FEHB plans you may request a certificate from them as well

40 42
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Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or
hospital has charged you for services you did not receive billed you twice for the same service or
misrepresented any information do the following

Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 1 800 ALERTED and explain the situation
If we do not resolve the issue call or write

THE HEALTH CARE FRAUD HOTLINE
202 418 3300
U S Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington D C 20415

Penalties for Fraud
Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud Also the
Inspector General may investigate anyone who uses an ID card if they

Try to obtain services for a person who is not an eligible family member or
Are no longer enrolled in the Plan and try to obtain benefits

Your agency may also take administrative action against you

41 43
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Summary of Benefits for BlueChoice HMO 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you
wish to enroll or change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE
EXCEPTION OF EMERGENCY CARE ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS

Inpatient Care
Hospital

Comprehensive range of medical and surgical services without dollar or day limit Includes in hospital doctor care room And board general nursing care private room and private nursing care if medically necessary diagnostic tests drugs
and medical supplies use of operating room intensive care and complete maternity care You pay nothing 17
Extended care
All necessary services for 60 days per member per calendar year You pay nothing 17
Mental conditions
Diagnosis and treatment of acute psychiatric conditions for up to 60 days of inpatient care per year You pay nothing 21
Substance abuse
Up to 30 days per year in a substance abuse treatment program You pay nothing 22
Outpatient care
Comprehensive range of services such as diagnosis and treatment of illness or inquiry including special's care preventive care including well baby care periodic check ups and routine immunizations laboratory tests and x rays complete
maternity care You pay a 10 copay per office visit copays are waived for maternity care and well child 10 per house call by a doctor 12

Home health care
All necessary visits by nurses and health aides You pay nothing 14
Mental conditions
Up to 60 outpatient visits per year You pay a 5 copay per visit 21
Substance abuse
Up to 60 outpatient visits maximum per year for the treatment of alcoholism and substance abuse you pay nothing 22
Emergency care
Reasonable charges for services and supplies required because of a medical emergency You pay a 35 copay to the hospital for each emergency room visit and any charges for services that are not covered by this Plan 19

42 44
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Prescription Drugs
Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5 copay per prescription unit or refill 23

Dental Care
Accidental injury benefit you pay nothing 26
Vision Care
No current benefit
Out of Pocket Maximum
Your out of pocket expenses for benefits covered under this Plan are limited to the stated copayments which are required for a few benefits 5

43 45
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2000 Rate Information for
BlueChoice HMO

Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the
FEHB Guide for that category or contact the agency that maintains your health benefits enrollment

Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution
rates referred to as Category A rates and Category B rates will apply for certain career employees If you are
a career postal employee but not a member of a special postal employment class refer to the category
definitions in The Guide to Federal Employees Health Benefits Plans for United States Postal Service
Employees RI 70 2 to determine which rate applies to you

Postal rates do not apply to non career postal employees postal retirees certain special postal employment
classes or associate members of any postal employee organization Such persons not subject to postal rates
must refer to the applicable Guide to Federal Employees Health Benefits Plans

Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Code Gov't Your Gov't Your USPS Your USPS Your Enrollment Share
Share Share Share Share Share Share Share

Downstate area
Self Only S71 78.83 38.05 170.80 82.44 93.06 23.82 93.26 23.62

Self and Family S72 175.97 137.47 381.27 297.85 207.74 105.70 201.02 112.42
Albany area
Self Only 5L1 67.53 22.51 146.32 48.77 79.91 10.13 79.91 10.13

Self and Family 5L2 175.97 60.13 381.27 130.28 207.74 28.36 201.02 35.08 46

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