Document Outline

Pages 1--32 from 79144H - coverYr2000 FEHB.qxd

For changes
and benefits
see page 4

Serving Oklahoma City Tulsa Lawton SW Oklahoma areas Enrollment in this Plan is limited see page 5 for requirements
Enrollment code N51 Self only
N52 Self and family

Visit the OPM Website at http www opm gov insure
and
our website at http www bcbsok com

Authorized for distribution by the
RI 73 267 1
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BlueLincs 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
Section 4 What to do if we deny your claim or request for service 9
Section 5 Benefits 11
Section 6 General exclusions Things we don't cover 20
Section 7 Limitations Rules that affect your benefits 21
Section 8 FEHB facts 23
Inspector General Advisory Stop Healthcare Fraud 27
Summary of benefits 28
Premiums back cover 2
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3
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BlueLincs HMO 2000
Introduction

BlueLincs HMO P O Box 3283
Tulsa OK 74102 3283
This brochure describes the benefits you can receive from BlueLincs under its contract CS2074 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 BlueLincs 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 4
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BlueLincs 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 5
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BlueLincs 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 6
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BlueLincs HMO 2000
Section 2 How we 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 of 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
Vision Care benefits are now available 7
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BlueLincs HMO 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

area The following Counties are eligible service areas in their entirety
Adair Grady Mayes Payne Canadian Greer McClain Pottawatomie
Cherokee Harmon McIntosh Rogers Cleveland Jackson Muskogee Stephens
Comanche Kiowa Okfuskee Tillman Cotton Lincoln Oklahoma Tulsa
Creek Logan Okmulgee Wagoner
You may also enroll with us if you live or work in the following places
The following zip codes are eligible Service Areas
73001 Albert 73434 Foster 73074 Paoli 73520 Addington 73040 Geary 73075 Pauls Valley
73005 Anadarko 74435 Gore 73476 Pernell 73035 Antioch 73042 Gracemont 73077 Perry
73006 Apache 73437 Graham 74060 Prue 74633 Apperson 73043 Greenfield 74561 Quinton
74001 Avant 74034 Hallett 74061 Ramona 74002 Barnsdall 73650 Hammon 73081 Ratliff City
74332 Big Cabin 73548 Hastings 73661 Rocky 73009 Binger 73444 Hennepin 73662 Sayre
74830 Bowlegs 73047 Hinton 74868 Seminole 74962 Box 74035 Hominy 73664 Sentinel
73625 Butler 74440 Hoyt 74070 Skiatook 74425 Canadian 74442 Indianola 74462 Stigler
73626 Canute 74038 Jennings 74081 Terlton 73015 Carnegie 73750 Kingfisher 73488 Tussy
73627 Carter 74552 Kinta 74368 Twin Oaks 73016 Cashion 74849 Konawa 74082 Vera
73017 Cement 74850 Lamar 74962 Vian 73628 Cheyenne 73052 Lindsay 74301 Vinita
74020 Cleveland 73053 Lookeba 73094 Washita 74837 Cromwell 73756 Loyal 73772 Watonga
73059 Cogar 73757 Lucien 73573 Waurika 73029 Cyril 73057 Maysville 74883 Wetumka
73641 Dill City 74048 Nowata 74884 Wewoka 74839 Dustin 74359 Oaks 74472 Whitefield
73644 Elk City 74051 Ochelata 74854 Wolf 73648 Elk City 73762 Okarche 73098 Wynnewood
73038 Fort Cobb 73764 Omega 73647 Foss 74054 Osage

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 benefits as described on page

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 BlueLincs HMO offers members Away from Home
Care You may receive a temporary guest membership from nearly 90 participating network HMOs from the U S for up to six months Eligibility and benefits may vary from Blue HMO to
Blue HMO For more information contact BlueLincs HMO at 1 800 722 5675 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 8
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BlueLincs HMO 2000
How much do You must share the cost of some services This is called either a copayment a set dollar I pay for services amount or coinsurance a set percentage of charges Please remember you must pay this amount
when you receive services except for those services covered at 100
After you pay 1,000 in copayments or coinsurance for one family member or 3,000 per family 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 service vision services and certain mental health and
substance abuse service 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 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 my BlueLincs HMO is an Individual Practice Association Health Maintenance Organization health care BlueLincs HMO offers each individual a choice of over 500 personal primary care doctors M D s
and D O s so that each family member can receive care that is best suited to them In addition the BlueLincs HMO provider network includes 36 major hospitals for inpatient care more than 400
pharmacy locations and over 1100 specialist doctors for referral care
Role of a primary The first and most important decision each member must make is the selection of a primary care doctor care doctor The decision is important since it is through this doctor that all other health
services particularly those of specialists are obtained It is the responsibility of your primary care doctor to obtain any necessary authorizations from the Plan before referring you to a specialist
or making arrangements for hospitalization Services of other providers are covered only when you have been referred by your primary care doctor A woman may see her Plan obstetrician gynecologist
for her annual examination without a referral Simply call a Member Services representative 1 800 722 5675 and tell him her that you are self referring to a participating
BlueLincs gynecologist A man may self refer to a Plan urologist once a year for a routine exam
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 into specialist will make the necessary hospital arrangements and supervise your care
the hospital
What do I do if First call our customer service department at 800 722 5675 If you are new to the FEHB I'm in the hospital Program we will arrange for you to receive care If you are currently in the FEHB Program
when I join this Plan and are switching to us your former plan will pay for the hospital stay until
You are discharged not merely moved to an alternative care center or 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 9
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BlueLincs HMO 2000
How do I get Your primary care physician will arrange your referral to a specialist Except in a medical specialty care emergency or when a primary care doctor has designated another doctor to see patients when he
or she is unavailable you must contact your primary care doctor for a referral before seeing any other doctor or obtaining special services Referral to a participating specialist is given at the
primary care doctor's discretion if specialists or consultants are required beyond those participating in the Plan the primary care doctor will make arrangements for appropriate referrals

When you receive a referral from your primary care doctor you must return to the primary care doctor after the consultation unless your doctor authorizes additional visits All follow up care must
be provided or authorized by the primary care doctor Do not go to the specialist for a second visit unless your primary care doctor has arranged for and the Plan has issued an
authorization for the referral in advance A female may self refer to a participating Bluelincs obstetrician gynecologist once a year for her annual examination The annual examination includes
pelvic exam pap smear and breast exam for the office visit copayment A referral from your primary care physician is not needed for this benefit Any follow up visits from this
provider MUST BE AUTHORIZED from your primary care physician All maternity care will continue to be coordinated by your primary care physician A male may self refer to a participating
BlueLincs urologist once a year for his annual examination The annual examination includes the office visit and prostate examination but it does not include the
Prostate Specific Antigen test PSA A referral from your primary care physician is not necessary Simply contact a Member Services representative to advise that you are self
referring If you are receiving services from a doctor who leaves the Plan the Plan will pay for covered services until the Plan can arrange with you to be seen by another participating doctor

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

The Plan will provide benefits for covered services only when the services are medically necessary to prevent diagnose or treat your illness or condition Your plan doctor must obtain
the Plan's determination of medical necessity before you may be hospitalized referred for specialty care or obtain follow up care from a specialist

What do I do if Your primary care physician will decide what treatment you need If they decide to refer you I am seeing a to a specialist ask if you can see your current specialist If your current specialist does not
specialist when participate with us you must receive treatment from a specialist who does Generally we will I enroll not pay for you to see a specialist who does not participate with our Plan

What do I do if Call your primary care physician who will arrange for you to see another specialist You may my specialist leaves receive services from your current specialist until we can make arrangements for you to see
the Plan someone else 10
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BlueLincs HMO 2000
But what if I Please contact us if you believe your condition is chronic or disabling You may be able to have a serious continue seeing your provider for up to 90 days after we notify you that we are terminating our
illness and my contract with the provider unless the termination is for cause If you are in the second or provider leaves the third trimester of pregnancy you may continue to see your OB GYN until the end of your
Plan or this Plan postpartum care leaves the Program
You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or
chronic condition or are in 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 Your physician must get our approval before sending you to a hospital referring you to a authorize specialist or recommending follow up care Before giving approval we consider if the service
medical services is medically necessary and if it follows generally accepted medical practice
Plan providers will follow generally accepted medical practice in prescribing any course of treatment Before you enroll in this Plan you should determine whether you will be able to
accept treatment or procedures that may be recommended by Plan providers
How do you decide The Plan uses a multi step process employing health care data analysis scientific literature if a service is review and clinical consensus to provide the highest level of confidence in its criteria and
experimental or protocols investigational 11
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BlueLincs 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
When may I ask You may ask OPM to review the denial after you ask us to reconsider our initial denial or OPM to review refusal OPM will determine if we correctly applied the terms of our contract when we denied
a denial your claim or request for service
What if I have a Call us at 1 800 722 5675 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 claim we will inform denied my request OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's
for care and my health benefits Contract Division IV at 202 606 0737 between 8 a m and 5 p m Serious or condition is serious life threatening conditions are ones that may cause permanent loss of bodily functions or death if
or life threatening 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 time limits 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 12
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BlueLincs HMO 2000
What do I send to Your request must be complete or OPM will return it to you You must send the following OPM information

1 A statement about why you believe our decision is wrong based on specific benefit provisions in this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim 4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to which claim

Where should I Send your request for review to Office of Personnel Management Office of mail my disputed Insurance Programs Contract Division IV P O Box 436 Washington D C
claim to OPM 20044
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 if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our upholds the Plan's decision your only recourse is to sue
denial If you decide to sue you must file the suit against OPM in Federal court by December 31 of the
third year after the year in which you received the disputed services or supplies
What laws apply if Federal law governs your lawsuit benefits and payment of benefits The Federal court will I file a lawsuit 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 collects from the Privacy Act 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 13
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BlueLincs 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
visit 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

You pay a 10 copay for each inpatient physician visit and any charges noted below
The following services are included
Preventive care including well baby care and periodic check ups

Mammograms are covered as follows for women age 35 through 39 one mammogram during these 5 years for women age 40 through 49 one mammogram every one or two years for

women age 50 through 64 one mammogram every two years In addition to routine screenings 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 office visit copays are waived for obstetrical care The

mother at her option may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a caesarean delivery Inpatient stays will be extended if medically necessary 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 insertion of IUDs and family planning services
Diagnosis and treatment of diseases of the eye
Vision and hearing screening up to age 19 one per year with referral to a specialist when appropriate

Allergy testing and treatment copay is not required if physician is not seen
Biological serum you pay 50 of covered charges
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Breast prostheses and surgical bras as well as their replacement

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 14
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BlueLincs HMO 2000
Medical and Surgical Benefits continued What is covered cont Cornea heart heart lung kidney liver lung single or double pancreas kidney and skin

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 breast cancer
multiple myeloma epithelial ovarian cancer and testicular mediastinal retroperitoneal and ovarian germ cell tumors Transplants are covered when approved by the Medical Director
Related medical and hospital expenses of the donor are covered when the recipient is covered by this Plan

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
Dialysis
Surgical treatment of morbid obesity
Chemotherapy radiation therapy and inhalation therapy

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
Chiropractic services
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 shortening of the mandible or maxillae for cosmetic purposes correction of malocclusion and any dental care involved in
treatment of temporo mandibular joint TMJ pain dysfunction syndrome
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 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 three consecutive months per condition if significant improvement can
be expected within three months you pay a 10 copay per visit 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

Durable medical equipment such as wheelchairs and hospital beds prosthetics such as lenses following cataract removal and orthopedic devices such as foot orthotics You pay 20
of all covered charges up to a maximum benefit of l 000 per member per calendar year

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 15
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BlueLincs HMO 2000
Medical and Surgical Benefits continued

Diagnosis and treatment of infertility is covered you pay 50 of all charges The following type s of artificial insemination are covered ICI IUI and IVI you pay 50 of all charges
cost of donor sperm is not covered Other assisted reproductive technology ART procedures such as in vitro fertilization and embryo transfer are not covered Fertility drugs are not
covered

What is not Physical examinations that are not necessary for medical reasons such as those required for covered obtaining or continuing employment or insurance attending school or camp or travel
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Hearing aids
Homemaker services
Long term rehabilitative therapy
Transplants not listed as covered
Blood and blood derivatives not replaced by the member
Cardiac rehabilitation

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 16
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BlueLincs 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 You pay a 10 copay for each
inpatient physician visit All necessary services are covered including
Semi private 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
Extended care The Plan provides a comprehensive range of benefits with no dollar or day limit 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 the home or a hospice facility Services include inpatient and outpatient 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 service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor

Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there procedures 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 detoxification diagnosis 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 17 or nonmedical substance abuse
benefits

What is not Personal comfort items such as telephone and television covered
Blood and blood derivatives not replaced by the member
Custodial care rest cures domiciliary or convalescent care
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 17
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BlueLincs HMO 2000
Emergency Benefits
What is a A medical emergency is the sudden and unexpected onset of a condition or an injury you medical believe endangers your life or could result in serious injury or disability and requires
emergency 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

Emergencies within If you are in an emergency situation please call your primary care doctor In extreme the service area 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 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 or on the first 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 and Plan doctors believe care can be better provided in a Plan hospital 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 or provided by Plan providers

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 and 25 per visit to a participating minor emergency or urgent care center 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 any 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 If a Plan doctor believes care can be better provided in a Plan hospital you will be transferred when medically feasible with any ambulance charges covered in full

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 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 18
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BlueLincs HMO 2000
Emergency Benefits continued
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 approved by the Plan
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 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 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 page 9

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 Up to 40 outpatient visits to Plan doctors consultants or other psychiatric personnel care each calendar year you pay a 20 copay for each covered visit all charges thereafter

Inpatient Up to 30 days of hospitalization each calendar year you pay nothing for first 30 care days all charges thereafter
What is not Care for psychiatric conditions that in the professional judgment of Plan doctors are not covered 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 that is not medically necessary to determine the appropriate treatment of a short term psychiatric condition

The medical management of mental conditions will be covered under this Plan's Medical and Surgical Benefits provisions Related drug costs will be covered under this Plan's Prescription Drug
Benefits and any costs for psychological testing or psychotherapy will be covered under this Plan's Mental Conditions Benefits

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 19
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BlueLincs HMO 2000
Mental Conditions Substance Abuse Benefits continued
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 Services for the psychiatric aspects are provided in conjunction with the mental conditions benefit shown above Outpatient visits to Plan mental
conditions providers for follow up care and counseling are covered as well as inpatient services necessary for diagnosis and treatment The mental conditions visit day limitations and
copays apply
What is not Treatment which is not authorized by a Plan doctor covered

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
generic drugs and a 10 copay per prescription unit or refill for name brand drugs Nonformulary drugs will be covered when prescribed by a Plan doctor

Formulary The Plan's formulary consists of a list of commonly prescribed medications that have
been chosen by the Plan based on a drug's effectiveness and cost The Plan will evaluate any needed additions to or deletions from the formulary Nonformulary drugs will be
covered when prescribed by a Plan doctor
Covered medications and accessories include
Drugs for which a prescription is required by law Oral contraceptive drugs
Contraceptive devices including Norplant injectable contraceptives Insulin
Disposable needles and syringes needed for injecting covered prescribed medications Intravenous fluids and medication for home use implantable drugs and some injectable
drugs are covered under Medical and Surgical Benefits Diabetic supplies including glucose test tablets and test tape Benedict's solution or
equivalent and acetone test tablets
What is not Drugs available without a prescription or for which there is a non prescription equivalent covered available
Drugs not FDA approved 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
Smoking cessation drugs and medication including nicotine patches Fertility drugs
Medications or devices used to retain or alter hair growth

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 20
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BlueLincs HMO 2000
Other Benefits
Dental care
Accidental injury Restorative services and supplies necessary to promptly repair and replace natural teeth The sound Benefit need for these services must result from an accidental injury that occurred while in a plan under
the FEHB Program you pay nothing
What is not Other dental services not shown as covered covered

Vision Care One routine vision exam by a Participating Vision Provider including refractions eye drops when necessary and glaucoma testing for at risk adults per member per 12 month period You pay
a 10 co payment per exam Frames lenses and contact lenses through a Participating Vision Provider at a 20 discount

What is not Disposable lenses covered 21
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BlueLincs HMO 2000
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 who are members of this Plan The cost of the benefits described on this page is not included in the FEHB premium any charges for these services do not count toward any FEHB deductibles out ofpocket
maximum copay charges etc These benefits are not subject to the FEHB disputed claims procedures

Voluntary Dental
ATTENTION As a federal employee are eligible to join BlueSelect Dental BlueSelect Dental benefit highlights include
Simple and Convenient You can select your dental care provider from a statewide network of more than 1,100 Participating

Providers
100 Coverage for Diagnostic and Preventative Services no deductible Oral examinations every six months

Cleaning scaling and polishing every six months Bitewing X Rays two per year
Full mouth X rays one during a five year period Fluoride application for children under age 19
Space maintainers for children under age 19 Sealants for children under age 14 with some restrictions

80 Coverage for Restorative Procedures after 50 deductible Fillings except gold
Simple extractions Root canal treatment
Extraction of impacted teeth Periodontic treatment of the gums
Repair of dentures General anesthesia when medically necessary for covered services

Annual Maximum Benefit 1,000 per person per calendar year Affordable Premiums
Monthly Rates Child Only Age 18 and under 14.10
Adult Only Age 19 over 18.80 Adult Spouse 36.10
Adult Spouse One Child 50.20 Adult Spouse Two or More Children 71.80
Adult One Child 32.90 Adult Two or More Children 54.50

Rates subject to change
For enrollment information call 800 378 2362 Consult the separate Plan description for additional information
When covered treatment is performed by a non participating dentist outside the network benefits will be covered at a lower benefit rate

ATTENTION The following benefit s are only available to BlueLincs Subscribers
5,000 Accidental Death and Dismemberment We're Giving You More Than You Asked For

Accidental Death Dismemberment insurance as part of your BlueLincs coverage
As a BlueLincs Subscriber you receive 5,000 in AD D coverage It's one more way BlueLincs provides you extra value

Benefits on this page are not part of the FEHB contract 22
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BlueLincs 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 or eligible self referred services
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 23
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BlueLincs 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
Other group When anyone has coverage with us and with another group health plan it is called double insurance coverage You must tell us if you or a family member has double coverage You must also
coverage 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 beyond our unable to provide them In that case we will make all reasonable efforts to provide you
control with necessary care
When others are When you receive money to compensate you for medical or hospital care for injuries or responsible for illness that another person caused you must reimburse us for whatever services we paid
injuries 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 24
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BlueLincs HMO 2000
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 agency Government directly or indirectly pays for
Agencies 25
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BlueLincs HMO 2000
Section 8 FEHB Facts
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives information about you the right to information about your health plan its networks providers and facilities
your HMO 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 800 722 5675 or write to BlueLincs HMO P O Box 3283 Tulsa OK 74102 3283 You may also contact us by fax at 918 561 9980
or visit our website at www bcbsok com
Where do I get Your employing or retirement office can answer your question and give you a Guide to information about Federal Employees Health Benefits Plans brochures for other plans and other materials
enrolling in the 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 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
available for me employing or retirement office authorizes coverage for Under certain circumstances you may and my family 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 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 26
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BlueLincs HMO 2000
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 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 We will send you an Identification ID card Use your copy of the Health Benefits Election cards 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 member had before conditions 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 or 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 spouse coverage benefits 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 27
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BlueLincs HMO 2000
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 32nd 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 If you leave Federal service your employing office will notify you of your right to enroll under in TCC 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 notify your employing or retirement office within the 60 day deadline

How can I convert You may convert to an individual policy if to individual
coverage Your coverage under TCC or the spouse equity law ends If you canceled 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 28
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BlueLincs HMO 2000
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 Plan Coverage Certificate of that indicates how long you have been enrolled with us You can use this certificate when
Group Health getting health insurance or other health care coverage You must arrange for the other coverage Plan 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 29
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BlueLincs HMO 2000
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 800 722 5675 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 30
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BlueLincs HMO 2000
Summary of Benefits for BlueLincs 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 Page
Inpatient Hospital Comprehensive range of medical and surgical services without care 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 a 10 copay per in hospital doctor visit 14

Extended care All necessary services no dollar or day limit You pay nothing 14
Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 conditions days of inpatient care per year You pay nothing 16

Substance Covered under Mental conditions benefit 17 abuse
Outpatient Comprehensive range of services such as diagnosis and treatment of care illness or injury including specialist's care preventive care including
well baby care periodic check ups and routine immunizations laboratory tests and X rays complete maternity care You pay 10
per office visit 10 per house call by a doctor 11
Home health All necessary visits by nurses and health aides You pay nothing 12 care

Mental Up to 40 outpatient visits per year You pay a 20 copay per conditions outpatient visit 16
Substance Covered under Mental conditions benefit 17 abuse
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 50 copay to the hospital for each
emergency room visit and any charges for services that are not covered benefits of the Plan 15

Prescription drugs Drugs prescribed by a Plan doctor and obtained at a participating pharmacy You pay 5 for Generic drugs and 10 for Name Brand
drugs per prescription unit or refill 17
Dental care Accidental injury benefit only You pay nothing 18
Vision care You pay 10 for a routine yearly exam by a Participating Vision Provider and receive a 20 discount on frames lenses and contact lenses through
a Participating Vision Provider 18
Out of pocket maximum Copayments are required for a few benefits however after your out of pocket expenses reach a maximum of 1,000 per Self Only
or 3,000 per Self and Family enrollment per calendar year covered benefits will be provided at 100 This copay maximum does not
include prescription drugs 6 31
31 Page 32
2000 Rate Information for
BlueLincs 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

OK City Tulsa Lawton SW Oklahoma areas Self Only N51 67.34 22.44 145.89 48.63 79.68 10.10 79.68 10.10
Self and Family N52 147.96 49.32 320.58 106.86 175.09 22.19 175.09 22.19 32

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