4
Serving North central New Mexico
Enrollment in this Plan is limited see page 5 for requirements
Enrollment code
PX1 Self Only
PX2 Self and Family
Visit the OPM website at http www opm gov insure
Authorized for distribution by the
United States
Office of
P e r s o n n e l
Management
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Qual Med Plans for Health 2000
Table of Contents
Page
Introduction 3
Plain language 3
How to use this brochure 3
Section 1 Health Maintenance Organizations 4
Section 2 How we change for 2000 4
Section 3 How to get benefits 5
Section 4 What to do if we deny your claim or request for service 7
Section 5 Benefits 9
Non FEHB benefits available to plan members 17
Section 6 General exclusions Things we don't cover 18
Section 7 Limitations Rules that affect your benefits 18
Section 8 FEHB facts 19
Information for new members 21
When you lose benefits 21
Inspector General Advisory Stop Healthcare Fraud 23
Summary of benefits Inside back cover
Premiums Back cover
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Qual Med Plans for Health 2000
Introduction
QualMed Plans for Health
6100 Uptown Blvd NE Suite 400
Albuquerque NM 87110
This brochure describes the benefits you can receive from QualMed Plans for Health Inc CS2062 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 five 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 QualMed Plans for Health 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
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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Qual Med Plans for Health 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 preventive
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
Section 2 How we change for 2000
Program wide changes To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary care office visits Office visit copayment is now 10 instead of 5
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
Changes to this Plan Your share of the non postal premium will increase by 10.9 for Self Only or 11 for Self and Family
A 90 day supply of covered maintenance medications is now available through the Mail
Order benefit for two copayments See Prescription Drug Benefits
Preventive and diagnostic dental services are covered subject to a 40 copayment per
visit instead of 30
Cardiac rehabilitation is now a covered benefit subject to a 10 copayment per session
See Medical and Surgical Benefits Limited benefits
Clarifications The following benefit descriptions have been clarified Oral and Maxillofacial Surgery Shortterm Rehabilitative Therapy Hospice care and internal prosthetic devices
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Qual Med Plans for Health 2000
Section 3 How to get benefits
What is this To enroll with us you must live or work in our service area This is where our providers
Plan's service practice Our service area is North Central New Mexico as described below
area Bernalillo All zip codes
Santa Fe All zip codes
Sandoval 87001 87004 87013 87018 87024 87025 87027 87041 87043 87044
87046 87048 87052 87053 87124 87174 87501
Valencia 87002 87006 87031 87042 87060 87068
Taos 87517 87521 87525 87529 87543 87549 87553 87557 87561 87571
87576 87579
Los Alamos 87544
Mora 87712 87713 87715 87722 87723 87725 87732 87736 87750
Torrance 87016 87032 87035 87036 87057 87061 87063 87070
Rio Arriba 87012 87017 87064 87510 87511 87516 87522 87523 87527 87530
87531 87532 87533 87537 87539 87548 87550 87566 87578 87581
87582
San Miguel 87536 87538 87542 87552 87560 87562 87565 87568 87569 87573
87583 87701 87731 87742 87745
Ordinarily you must get your care from providers who contract with us If you receive care
outside our service area we will pay only for emergency care We will also reimburse routine
care received at Student Health Care Centers at the out of area colleges or universities that your
covered dependent children attend less the office visit copayment We will not pay for any other
health care services
If you or a covered family member move outside of our service area you can enroll in another
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 You must share the cost of some services This is called either a copayment a set dollar amount
do I pay or coinsurance a set percentage of charges Please remember you must pay this amount when
for services you receive services
After you pay 3,194 in copayments or coinsurance for Self Only enrollment or 8,432 for Self
and Family enrollment you do not have to make any further payments for certain services for the
rest of the year This is called a catastrophic limit However copayments or coinsurance for your
prescription drugs dental services and substance abuse rehabilitation benefits do not count
toward these limits and you must continue to make these payments
Be sure to keep accurate records of your copayments and coinsurance since you are responsible
for informing us when you reach the limits
Do I have to You normally won't have to submit claims to us unless you receive emergency services from a
submit claims provider who doesn't contract with us If you file a claim please send us all of the documents for your claim as soon as possible You must submit claims within 90 days of the date the service
was rendered Either OPM or we can extend this deadline if you show that circumstances beyond
your control prevented you from filing on time
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Qual Med Plans for Health 2000
Section 3 How to get benefits continued
Who provides QualMed Plans for Health is an individual practice plan that provides care to members through
my health an extensive list of private practice doctors and other providers located conveniently throughout
care the North Central New Mexico areas The doctor panel consists of over 300 primary care doctors
and over 900 specialists
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 physician or
I need to go specialist will make the necessary hospital arrangements prior authorize them with the Plan and
into the hospital supervise your care
What do I do if First call our customer service department at 800 365 0009 If you are new to the FEHB
I'm in the Program we will arrange for you to receive care If you are currently in the FEHB Program and
hospital when are switching to us your former plan will pay for the hospital stay until
I join this 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
How do I get Your primary care physician will request your referral to a specialist from the Plan's Medical
specialty care Director Your doctor may call fax or mail his request to the Plan Services of other providers are covered only when there has been a Plan approved referral by your primary care doctor with
the following exception a woman may see her Plan obstetrician gynecologist directly without a
referral for obstetrical or gynecological care
If you need to see a specialist frequently because of a chronic complex or serious medical
condition your primary care physician will present a treatment plan for consideration to the Plan's
Medical Director This treatment plan would allow 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 Your primary care physician will decide what treatment you need and will request a specialist
if I am seeing a referral from the Plan If your physician decides to refer you to a specialist ask if you can see
specialist when your current specialist If your current specialist does not participate with us you must receive
I enroll treatment from a specialist who does Generally we will not pay for you to see a specialist who
does not participate with our Plan
What do I do Call your primary care physician who will arrange for you to see another specialist You may
if my specialist receive services from your current specialist until we can make arrangements for you to see
leaves the Plan someone else
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Qual Med Plans for Health 2000
Section 3 How to get benefits continued
But what if I have Please contact us if you believe your condition is chronic or disabling You may be able to
a serious illness continue seeing your provider for up to 90 days after we notify you that we are terminating our
and my provider contract with the provider unless the termination is for cause If you are in the second or third
leaves the Plan or trimester of pregnancy you may continue to see your OB GYN until the end of your postpartum
this Plan leaves 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
How do you authorize Your physician must get our approval before sending you to a hospital referring you to a
medical services specialist or recommending follow up care Before giving approval we consider if the service is medically necessary and if it follows generally accepted medical practice
How do you decide The Plan's experimental investigational determination process is based upon authoritative
if a service is information obtained from medical literature medical specialist opinion and evidence from
experimental or State and Federal government agencies and research organizations including FDA
investigational
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
When may I ask You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal
OPM to review OPM will determine if we correctly applied the terms of our contract when we denied your claim
a denial or request for service
What if I have a serious Call us at 800 365 0009 and we will expedite our review
or life threatening
condition and you
haven't responded to
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Qual Med Plans for Health 2000
Section 4 What to do if we deny your claim or request for service continued
What if you have If we expedite your review due to a serious medical condition and deny your claim we will
denied my request inform OPM so that they can give your claim expedited treatment too Alternatively you can call
for care and my OPM's health benefits Contract Division IV at 202 606 0737 between 8 a m and 5 p m Serious
condition is serious or life threatening conditions are ones that may cause permanent loss of bodily functions or death
or life threatening if they are not treated as soon as possible
Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our
time limits initial denial or refusal of service You may also ask OPM to review your claim if
1 We did 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 Your request must be complete or OPM will return it to you You must send the following
to OPM information
1 A statement about why you believe our decision is wrong based on specific benefit
provisions in this brochure
2 Copies of documents that support your claim such as physicians letters operative
reports bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to
which claim
Who can make 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
Where should I mail Send your request for review to Office of Personnel Management Office of Insurance Programs
my disputed claim Contract Division IV P O Box 436 Washington D C 20044
to OPM
What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our
upholds the decision your only recourse is to sue
Plan's 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
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Qual Med Plans for Health 2000
Section 4 What to do if we deny your claim or request for service continued
What laws apply Federal law governs your lawsuit benefits and payment of benefits The Federal court will base
if I file a lawsuit its review on the record that was before OPM when OPM made its decision on your claim You may recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment
services supplies or drugs covered by us until you have completed the OPM review procedure
described above
Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you
the Privacy Act and us to determine if our denial of your claim is correct The information OPM collects during the review process becomes a permanent part of your disputed claims file and is subject to the
provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this
information to support the disputed claim decision If you file a lawsuit this information will
become part of the court record
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
visit copay but no additional copay for laboratory tests and X rays a 3 copay per visit for the
administration of allergen antigens Within the service area house calls will be provided if in
the judgment of a Plan doctor such care is necessary and appropriate you pay 15 copay for a
doctor's house call nothing for home visits by nurses and health aides
The following services are included and are subject to the office visit copay unless stated other
wise
Preventive care including well baby care and periodic check ups
Mammograms are covered as follows baseline mammogram for women between
35 and 40 years of age and an annual mammogram for women 40 to 65 years of age
In addition to routine screening mammograms are covered when prescribed by the
doctor as medically necessary to diagnose or treat your illness
Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal
delivery and postnatal care by a Plan doctor The mother at her option may remain in
the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery
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
Women who undergo mastectomies may at their option have this procedure performed
on an inpatient basis and remain in the hospital up to 48 hours after the procedure
Voluntary sterilizations and family planning services
Diagnosis and treatment of diseases of the eye
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Qual Med Plans for Health 2000
Section 5 BENEFITS continued
Allergy testing and treatment including test and treatment materials such as allergy
serum you pay a 3 copayment per visit in addition to the office visit copay
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Penile implants are limited to the treatment of impotence due to an organic cause
Cornea heart single lung double lung heart lung pancreas kidney and liver
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 lymphocytic leukemia advanced Hodgkin's
lymphoma advanced non Hodgkin's lymphoma advanced neuroblastoma aplastic
anemia Wiskott Aldrich Syndrome testicular mediastinal retroperitoneal and ovarian
germ cell tumors breast cancer multiple myeloma and epithelial ovarian cancer may
be provided as part of a peer reviewed non random clinical trial approved under the
guidelines of the National Institutes of Health Food and Drug Administration or
Veterans Administration Related medical and hospital expenses of the donor are
covered when the recipient is covered by this Plan Transplants are covered only
when determined to be medically appropriate by the QualMed Transplant Evaluation
Committee
Dialysis
Chemotherapy radiation therapy respiratory therapy inhalation therapy
Surgical treatment of morbid obesity
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
Limited benefits Oral and maxillofacial surgery is provided for nondental 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 the 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 TMJ disorders are covered only
when documented by radiographic evidence of disease or injury to the bone or articular surfaces
Coverage of TMJ disorders does not include orthodontics dental appliances or prosthetics unless
the disorder is trauma related
Reconstructive surgery will be 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 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 two consecutive months per condition if significant
improvement can be expected within two months Therapy may be extended upon
recommendation of the participating provider in consultation with QualMed 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 Treatment of
chronic conditions and maintenance therapy after maximum medical improvement is achieved are
not covered
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Qual Med Plans for Health 2000
Section 5 BENEFITS continued
Cardiac rehabilitation is covered limited to a maximum of 36 sessions per cardiac event You
pay a 10 copayment per session Physical therapy and occupational therapy are not covered
when furnished in connection with cardiac rehabilitation unless there is also a diagnosed noncardiac
condition requiring such therapy
Orthopedic appliances such as braces prosthetic devices such as artificial limbs external
lenses following cataract removal breast prostheses and surgical bras durable medical
equipment such as standard wheelchairs hospital beds and oxygen are covered you pay 20
of charges up to a combined maximum Plan payment of 2,000 per calendar year Non rigid
devices appliances and supplies such as elastic knee supports garter belts and corsets are not
covered
Contraceptive devices including implantable devices and Norplant are covered you pay 50
of charges up to a combined maximum Plan payment of 2,000 per calendar year
Chiropractic services are provided on a short term basis for acute conditions for up to 20 visits
per calendar year on referral from your Plan doctor You pay 50 of charges
Diagnosis and treatment of infertility is covered you pay 50 of charges The following types
of artificial insemination are covered intravaginal insemination IVI intracervical insemination
ICI and intrauterine insemination IUI you pay 50 of charges Fertility drugs are covered
you pay 50 of charges The cost of donor sperm is not covered Other assisted reproductive
technology ART procedures such as in vitro fertilization and embryo transfer are not covered
What is not covered Physical examinations and immunizations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance attending
school or camp or travel
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Homemaker services
Hearing aids
Long term rehabilitative therapy
Pulmonary rehabilitation
Services of rolfers and naturopaths
Transplants not listed as covered
Refractions including lens prescription
Corrective eyeglasses and frames or contact lenses including the fitting of the lenses
Foot orthotics such as shoe inserts
Radial keratotomy and keratoplasty
Wigs
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 as intensive care or cardiac care units
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Qual Med Plans for Health 2000
Section 5 BENEFITS continued
Extended care The Plan provides a comprehensive range of benefits for up to 30 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 family member is covered in the home or
hospice facility 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 Hospice
benefits are limited to 10,000 in a member's lifetime
Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor You
pay a 50 copay per trip for ground ambulance and a 100 copay per trip for air ambulance
Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a primary care doctor determines
procedures 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 care diagnosis
detoxification treatment of medical conditions and medical management of withdrawal symptoms acute detoxification if the Plan doctor determines that outpatient management is not medically
appropriate See page 15 for nonmedical substance abuse benefits
What is not covered Personal comfort items such as telephone and television Blood and blood derivatives not replaced by the member
Custodial care rest cures domiciliary or convalescent care
Take home drugs
Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you
emergency 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 bones Others are
emergencies because they are potentially life threatening such as heart attacks strokes
poisonings gunshot wounds or sudden inability to breathe 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
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Qual Med Plans for Health 2000
Section 5 BENEFITS continued
Emergencies within If you are in an emergency situation please call your primary care doctor or if your doctor is not
the service area available call the QualMed 24 hour Healthline on 800 564 8596 In extreme emergencies if you
are unable to contact your doctor contact the local 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 Plan You or a family member must
notify the Plan within 48 hours on the first business day following your admission or as soon as
medically possible It is your responsibility to ensure that the Plan has been timely notified
If you need to be hospitalized the Plan must be notified within 48 hours on the first business day
following your admission or as soon as medically possible If you need to be hospitalized in a
non Plan facility the Plan must be notified within 48 hours or on the next working day following
your admission unless it was not reasonably possible to notify the Plan within that time If you
are hospitalized in non Plan facilities you will be transferred when medically feasible with any
ambulance charges covered in full
Benefits are available for care from non Plan providers in a medical emergency only if delay in
reaching a Plan provider would result in death disability or significant jeopardy to your condition
To be covered by this Plan any follow up care recommended by non Plan providers must be
approved by the Plan in advance
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if
received from Plan providers
You pay 50 per hospital emergency room visit or 25 per urgent care center visit for emergency services
that are covered benefits of this Plan If the emergency results in admission to a hospital the
emergency care copay is waived
Emergencies outside Benefits are available for a medically necessary health service that is immediately required
the service area because of injury or unforeseen illness
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working
day following your admission unless it was not reasonably possible to notify the Plan within that
time You will be transferred to a Plan hospital when medically feasible with any ambulance
charges covered in full
To be covered by this Plan any follow up care recommended by non Plan providers must be
approved by the Plan
Plan pays Reasonable charges for emergency care services to the extent the services would have been
covered if received from Plan providers
You pay 50 per hospital emergency room visit or 25 per urgent care center visit for emergency services
that are covered benefits of this Plan If the emergency results in admission to a hospital the
emergency care 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 doctors services
Ambulance service if approved by the Plan you pay a 50 copay per trip for ground
ambulance and a 100 copay per trip for air ambulance
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Qual Med Plans for Health 2000
Section 5 BENEFITS continued
What is not covered Elective care or nonemergency care 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 non Plan providers
With your authorization the Plan will pay benefits directly to the providers of 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 provision 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 page 7 Submit emergency claims promptly as the Plan will not consider such
claims more than 90 days after the date of service
Mental Conditions Substance Abuse Benefits
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
Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Outpatient care Up to 20 outpatient visits to Plan doctors or other Plan psychiatric personnel each calendar year
you pay a 20 copay for each covered visit all charges thereafter
Inpatient care Up to 30 days of hospitalization each calendar year you pay nothing for the first 30 days all
charges thereafter
What is not covered Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to significant improvement through relatively short term 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 when not medically necessary to determine the appropriate
treatment of a short term psychiatric condition
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Qual Med Plans for Health 2000
Section 5 BENEFITS continued
Substance abuse
What is covered The 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
Outpatient Up to 20 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar
psychiatric care year you pay a 20 copay for each covered visit all charges thereafter
Inpatient Up to 30 days per calendar year for the medically necessary treatment of the psychiatric aspects of
psychiatric care substance abuse you pay nothing
Outpatient Up to 30 outpatient visits per calendar year lifetime maximum of 60 visits per member to Plan
rehabilitation care rehabilitation providers for treatment you pay 50 of the charges for each covered visit all
charges thereafter
Inpatient Up to 30 days per calendar year in a substance abuse rehabilitation intermediate care program in
rehabilitation care an alcohol detoxification or substance abuse rehabilitation center approved by the Plan lifetime
maximum of 60 days per member you pay 50 of the charges during the benefit period all
charges thereafter
What is not covered Treatment that is not authorized by a Plan doctor
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 or 100 unit dose whichever is less or manufacturer's
standard package size including inhalers you pay a 5 copay for generic drugs or an 8 copay
for name brand drugs when generic substitution is not permissible per prescription unit or refill
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 8 copay per
prescription unit or refill A 90 day supply of covered maintenance medications prescribed by a
Plan or referral doctor can be obtained through the mail order drug program for two copays To
access our mail order drug program contact us at 800 365 0009
Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary
The Plan's drug formulary is based on effectiveness and cost Nonformulary drugs will be
covered when prescribed by a Plan doctor
Covered medications and accessories include
Drugs for which a prescription is required by Federal law
Full range of FDA approved drugs prescriptions and devices for birth control
Contraceptive devices including implanted devices and implantable drugs such as
Norplant are covered under Medical and Surgical Benefits as a Limited benefit
Compounded dermatological preparations
Nitroglycerin Phenobarbital or Thyroid U S P
Insulin with a copay charge applied to every two vials
Fertility drugs are covered under Infertility benefits see page 11
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Qual Med Plans for Health 2000
Section 5 BENEFITS continued
Intravenous fluids and medication for home use implants and some injectible drugs are
covered under Medical and Surgical Benefits
Disposable needles and syringes needed to inject covered prescribed medication for up to
a 30 day supply or 100 units
Diabetic supplies incuding insulin syringes needles glucose test tablets and test tape
Benedict's solution or equivalent glucose monitors and acetone test tablets
Limited benefits Drugs to treat sexual dysfunction are limited Contact the Plan for dose limits You pay 50 coinsurance up to the dosage limits and all charges above that
Growth hormones You pay 20 of charges
What is not covered Drugs available without a prescription or for which there is a non prescription 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
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Drugs to aid dieting unless for morbid obesity
Drugs to aid in smoking cessation including nicotine gum and patches
Other Benefits
Dental care
What is covered
Preventive and diagnostic The following preventive and diagnostic services are provided by participating Plan dentists You pay a 40 copay per visit for all services performed on the same day This benefit is limited
to two visits per year and includes
Oral examination
Prophylaxis cleaning
X rays bitewings and panoramic film
Pulp vitality tests
Diagnostic casts
Fluoride application children and adults
Accidental injury benefit 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 and not biting or chewing
You pay a 5 copay per visit
What is not covered Other dental services not shown as covered
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Non FEHB Benefits Available to Plan Members
The benefits 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 who are 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 of pocket
maximums These benefits are not subject to the FEHB disputed claims procedures
Vision Benefits at no additional premium
Your vision exam and eyewear purchase are covered by QualMed through the Vision Service Plan
No referral is necessary Simply telephone a participating provider shown on the back of the
benefit listing and make an appointment for your refraction You pay 10 You and your covered
family members may each have one refraction every 12 months
Eyewear is available in most doctor's offices If your doctor does not offer eyewear you may take
your prescription to another location on the Vision Service Plan provider listing
Each covered family member will receive an initial 20 discount on his eyewear selection
followed by an additional 55 discount each You and your covered family members are allowed
one purchase each 24 months
Remember this benefit is for routine eye care Medically necessary diagnostic eye care is available
by referral under your FEHB Medical and Surgical benefits
For a complete listing of the Vision Service Plan benefits and providers please call QualMed at
800 365 0009 or 505 889 8800
Medicare prepaid plan enrollment QualMed Plans for Health offers Medicare recipients the
opportunity to enroll in the Plan through Medicare As indicated on page 18 annuitants and
former spouses with FEHB coverage and Medicare Part B may elect to drop their FEHB coverage
and enroll in a Medicare prepaid plan when one is available in their area They may then later
reenroll in the FEHB Program Most Federal annuitants have Medicare Part A Those without
Medicare Part A may join this Medicare prepaid plan but will probably have to pay for hospital
coverage in addition to the Part B premium Before you join the plan ask whether the plan
covers hospital benefits and if so what you will have to pay Contact your retirement system for
information on dropping your FEHB enrollment and changing to a Medicare prepaid plan Contact
us at 505 889 8800 or 505 365 0009 for information on the Medicare prepaid plan and the cost of
that enrollment
Benefits on this page are not part of the FEHB contract
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Qual Med Plans for Health 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
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 reenroll
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
Other group When anyone has coverage with us and with another group health plan it is called double
insurance coverage coverage You must tell us if you or a family member has double coverage You must also send us documents about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other
plan is secondary it pays benefits next We decide which insurance is primary according to the
National Association of Insurance Commissioners Guidelines
If we pay second we will determine 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
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Qual Med Plans for Health 2000
Section 7 Limitations Rules that affect your benefits continued
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
beyond our control provide them In that case we will make all reasonable efforts to provide you with necessary care
When others are When you receive money to compensate you for medical or hospital care for injuries or illness
responsible for injuries that another person caused you must reimburse us for whatever services we paid for We will cover the cost of treatment that exceeds the amount you received in 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
Workers compensation We do not cover services that
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 Government We do not cover services and supplies that a local State or Federal Government agency directly Agencies or indirectly pays for
Section 8 FEHB FACTS
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the
information about right to information about your health plan its networks providers and facilities You can also
your HMO 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 800 365 0009 or write to 6100 Uptown Blvd NE
Suite 400 Albuquerque NM 87110 You may also contact us by fax at 800 889 8819
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Qual Med Plans for Health 2000
Section 8 FEHB FACTS continued
Where do I get Your employing or retirement office can answer your questions and give you a Guide to
information about Federal Employees Health Benefits Plans brochures for other plans and other materials you need
enrolling in the 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 plan your
benefits and coverage and premiums begin on the first day of your first pay period that starts on or after
premiums January 1 Annuitants premiums begin January 1
effective
What happens When you retire you can usually stay in the FEHB Program Generally you must have been
when I retire 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 spouse and your
coverage are unmarried dependent children under age 22 including any foster or step children your employing
available for my or retirement office authorizes coverage for Under certain circumstances you may also get
family and me 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
give birth or add 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
Are my medical and We will keep your medical and claims information confidential Only the following will have
claims records 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 payment and
subrogating claims
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Qual Med Plans for Health 2000
Section 8 FEHB FACTS continued
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
Information for new members
Identification cards We will send you an Identification ID card Use your copy of the Health 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 conditions We will not refuse to cover the treatment of a condition that you or a family 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 when
my enrollment 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 to get benefits
spouse coverage under your former spouse's enrollment But you may be eligible 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
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
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Qual Med Plans for Health 2000
When you lose benefits continued
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
How do I enroll in TCC If you leave Federal service your employing office will notify you of your right 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 he becomes
eligible for TCC or you 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 him her 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
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 your coverage
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
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Qual Med Plans for Health 2000
When you lose benefits continued
How can I get If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage
a Certificate of that indicates how long you have been enrolled with us You can use this certificate when getting
Group Health health insurance or other health care coverage You must arrange for the other coverage within 63
Plan Coverage 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
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 800 365 0009 and explain the situation
If we do not resolve the issue call or write
THE HEALTH CARE FRAUD HOTLINE
202 418 3300
The Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington DC 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 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
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Qual Med Plans for Health 2000
Summary of Benefits for QualMed Plans for Health 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
Benefits Plan pays provides
Inpatient care
Hospital Comprehensive range of medical and surgical services with no 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 drug and medical supplies use of
operating room intensive care and complete maternity care You pay nothing 11
Extended All necessary services up to 30 days per year You pay nothing 12
care
Mental Diagnosis and treatment of acute psychiatric conditions for 30 days of inpatient care per
conditions year You pay nothing 14
Susbstance Diagnosis and treatment of the psychiatric aspects of substance abuse for up to 30 days of
abuse inpatient care per year You pay nothing Up to 30 days of rehabilitation services each
year up to a lifetime maximum of 60 days You pay 50 of charges 15
Outpatient care Comprehensive range of services such as diagnosis and treatment of illness or injury including specialist's care preventative 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 15 per house call by a doctor 9
Home health All necessary visits by nurses and health aides You pay nothing 10
care
Mental Up to 20 outpatient visits per year You pay 20 copay per visit 14
conditions
Substance Up to 20 outpatient visits per year for treatment of the psychiatric aspects of substance
abuse abuse You pay a 20 copay per visit Up to 30 outpatient rehabilitation visits per year
with a lifetime maximum of 60 visits per member You pay 50 of charges 15
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 25 copay to a participating urgent care center a 50 copay to the hospital for
each emergency room visit and any charges for services that are not covered by this Plan 12
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5 copay for generic drugs and an 8 copay per generic prescription unit or refill Maintenance
medications are available through the mail order program at a 90 day supply for two
copays 15
Dental care Accidental injury benefits You pay a 5 copay per visit preventive and diagnositc dental care You pay 40 per visit maximum of two visits per year 16
Vision care No current benefits see page 17 for coverage under Non FEHBP Benefits 17
Out of pocket Copayments are required for a few benefits however after your out of pocket expenses
expenses reach a maximum of 3,194 per Self Only or 8,432 per Self and Family enrollment per calendar year covered benefits will be proviced at 100 This copay maximum does not
include the cost of prescription drugs alcohol or chemical dependency rehabilitation
24 or dental care 5
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2000 Rate Information for
QualMed Plans for Health
Non Postal rates apply to most non Postal employees 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 Benefit 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 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 Employee
Health Benefit 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
Albuquerque Santa Fe areas
Self Only PX1 57.68 19.23 124.98 41.66 68.26 8.65 68.26 8.65
Self and Family PX2 152.27 50.76 329.93 109.97 180.19 22.84 180.19 22.84
25