Enrollment in this Plan is limited see page 6 for requirements
Enrollment Code
G21 Self Only
G22 Self and Family
This Plan has full accreditation
from the NCQA See the 2000 Guide
for more information on NCQA
Visit the OPM website at http www opm gov insure
and
this Plan's website at http www arnettplans com
Authorized for distribution by the
United States Office of
Personnel Management
Retirement and Insurance
R1 73 288
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Arnett HMO Health Plan 2000
Table of Contents
Introduction 3
Plain language 3
How to use this brochure 4
Section 1 Health Maintenance Orgainizations 4
Section 2 How we change for 2000 5
Section 3 How to get benefits 6
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 18
Section 7 Limitations Rules that affect your benefits 19
Section 8 FEHB Facts 20
Inspector General Advisory Stop Healthcare Fraud 24
Summary of benefits Inside back cover
Premiums Back cover
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Arnett HMO Health Plan 2000
Introduction
Arnett HMO 415 N 26th Street Suite 101 Lafayette IN 47903 6108
This brochure describes the benefits you can receive from Arnett HMO under its contact CS 2171 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 5 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 Arnett 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 re written the Benefits section of this brochure You will find the new benefits language next year
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Arnett HMO Health Plan 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
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
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and
other providers that contract with us These providers coordinate your health care services The care you receive includes
preventative care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and
injury
When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay
copayments and coinsurance listed in this brochure When you receive emergency services you may have to submit claim forms
You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change
plans because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider will be available
and or remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of
treatment
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Section 2 How we change for 2000
Program wide To keep your premiums as low as possible OPM has set a minimum copay of 10 for all primary care changes office visits
This year you have a right to more information about this Plan care management our networks facilities
and providers
If you have a chronic or disabling condition and your provider leaves the Plan at our request you may
continue to see your specialist for up to 90 days If your provider leaves the Plan and you are in the
second or third trimester of pregnancy you may be able to continue seeing your OB GYN until the end
of your postpartum care You have similar rights if this Plan leaves the FEHB program See Section 3
How to get benefits for more information
You may review and obtain copies of your medical records on request If you want copies of your
medical records ask your health care provider for them You may ask that a physician amend your
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 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 Your share of the standard option premium will decrease by 5.9 for Self Only or 2.4 for Plan Self and Family
Extended Care or Skilled Nursing Care has a limit of 120 days per calendar year with no dollar limit
Emergency Care whether in or out of service area has a 50 copayment per visit which will be waived
if admitted
Urgent Care at Arnett Clinic has a 15 copayment per visit
Outpatient Mental Health has a 10 copayment per visit with no day limit
Inpatient Mental Health has no day limit or copayments but must be referred by your Primary Care
Physician and prior authorized by the Plan
Outpatient Substance Abuse has a 20 copayment per visit with a maximum of 20 visits per calendar year
Inpatient Substance Abuse has a benefit of up to 30 days of hospitalization per calendar year with no
copayment per day for the first 30 days and all charges thereafter
Generic Drugs are covered with a 5 copayment
Formulary Brand Name Drugs are covered with a 15 copayment If a generic drug is available and the
prescription is filled with a formulary brand name drug member pays the difference in cost in addition to
the 15 copayment
Non Formulary Brand Name Drugs are now covered at a 30 copayment If a generic drug is available
and the prescription is filled with a non formulary brand name drug member pays the difference in cost
in addition to the 30 copayment
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Arnett HMO Health Plan 2000
Section 3 How to get benefits
What is this To enroll with us you must reside in or within 30 miles of one of our counties or within 30 miles of any Plan's service Plan Primary Care Physician in our network This is where our providers practice Our service area for
area this Plan are available in the following area The Greater Lafayette Indiana area including the counties of Benton Boone Carroll Cass Clinton Fountain Fulton Howard Jasper Montgomery Newton Pulaski
Tippecanoe Warren and White counties
Ordinarily you must get your care from our providers who contract with us If you receive care outside
our service area we will pay only for emergency care 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 In this plan the family member would only be covered for emergency care For routine
maintenance or illness they would need to be seen in plan If you or a family member move you do not
have to wait until Open Season to change plans Contact your employing or retirement office
How much do I You must share the cost of some services This is called either a copayment a set dollar amount or pay for services coinsurance a set percentage of charges Please remember you must pay this amount when you receive
services
Do I have to You normally won't have to submit claims to us unless you receive emergency services from a provider submit claims 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 Arnett HMO is a group model HMO There are over 250 participating physicians Plan members may health care select their primary care physicians among the participating family practice physicians internists
pediatricians or obstetrician gynecologists
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 specialist will I need to go into make the necessary hospital arrangements and supervise your care
the hospital
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What do I do First call our member services department at 765 448 7440 or toll free at 888 448 7440 If you are new if I'm in the to the FEHB Program we will arrange for you to receive care If you are currently in the FEHB Program
hospital when and 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 become a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do I get Except in medical emergency or when a primary care physician has designated another doctor to see specialty care patients when he or she is unavailable you must receive a referral from your primary care physician
before seeing any other doctor or obtaining special services Referral to a participating specialist is given
at the primary care physician's discretion if specialists or consultants are required beyond those
participating in the Plan the primary care physician will make arrangements for appropriate referrals
When you receive a referral from your primary care physician you must return to the primary care
physician after the consultation All follow up care must be provided or arranged by the primary care
physician Do not go to the specialist unless your primary care physician has arranged for and the Plan
has issued an authorization for the referral in advance
If you need to see a specialist frequently because of a chronic complex or serious medical condition
your primary care physician will develop a treatment plan that allows you to see your specialist for a
certain number of visits without additional referrals Your primary care physician will use our criteria
when creating your treatment plan
What do I do if Your primary care physician will decide what treatment you need If they decide to refer you to a I am seeing a specialist ask if you can see your current specialist If your current specialist does not participate with us
specialist when you must receive treatment from a specialist who does Generally we will not pay for you to see a I enroll 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 receive my specialist
services from your current specialist until we can make arrangements for you to see someone else
leaves the Plan
But what if I have Please contact us if you believe your condition is chronic or disabling You may be able to continue a serious illness
seeing your provider for up to 90 days after we notify you that we are terminating our contract with the
and my provider provider unless the cause for termination is for cause If you are in the second or third trimester of leaves the Plan or
pregnancy you may continue to see your OB GYN until the end of your postpartum care
this Plan leaves the Program
You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and
you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic
condition or are in your second or third trimester Your new plan will pay for or provide your care for up
to 90 days after you receive notice that your prior plan is leaving the FEHB Program If you are in your
second or third trimester your new plan will pay for the OB GYN care you receive from your current
provider until the end of your postpartum care
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How do you Your physician must get our approval before sending you to a hospital referring you to a specialist or authorize medical recommending follow up care Before giving approval we consider if the service is medically necessary
services and if it follows generally accepted medical practice For referrals to out of Plan providers you should receive written authorization by the Plan before treatment
How do you decide The Plan will apply the following criteria in determining whether services or supplies are experimental or if a service is investigational
experimental or investigational Any medical device drug or biological product must have received final approval to market by the
United States Food and Drug Administration FDA for the particular diagnosis or condition
Conclusive evidence from the published peer review medical literature must exist that the technology
has a definite positive effect on health outcomes such evidence must include well designed
investigations that have been reproduced by nonaffiliated authoritative sources with measurable
results back up by the positive endorsements of national medical bodies or panels regarding efficacy
and rationale
Demonstrated evidence as reflected in the published peer review medical literature must exist that
over time the technology leads to improvement in health outcomes i e the beneficial effects
outweigh any harmful effects
Proof as reflected in the published peer reviewed literature must exist that the technology is at least as
effective in improving health outcomes as established technology or is usable in appropriate clinical
contexts in which established technology is not employable
Proof as reflected in the published peer reviewed medical literature must exist that improvements in
health outcomes as defined in paragraph c is possible in standard conditions of medical practice
outside clinical investigatory settings
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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 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
the denial or request for service
What if I have Call us at 765 448 7440 or toll free at 888 448 7440 and we will expedite our review a 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 OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's
request for care health benefits Contract Division IV at 202 606 0737 between 8 a m and 5 p m Serious or lifethreatening and my condition conditions are ones that may cause permanent loss of bodily functions or death if they
is serious or life are not treated as soon as possible threatening
Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our initial time limits denial or refusal of service You may ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your request within
120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30 days In
this case OPM must receive your request within 120 days of the date we asked you for additional
information
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What do I send to Your request must be complete or OPM will return it to you You must send the following information OPM
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 Medical providers legal counsel and other
interested parties who are acting as the enrolled person's representative They must send a copy of
the person's specific written consent with the review request
What address Send your request for review to Office of Personnel Management Office of Insurance Programs should I send my Contracts Division IV P O Box 436 Washington D C 20044
disputed claim to
What if OPM OPM's decision if final There are no other administrative appeals If OPM agrees with our decision upholds the 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
What laws apply Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its if I file a lawsuit 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
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 and the Privacy Act us to determine if our denial of your claim is correct The information OPM collects during the review
process becomes a permanent part of your disputed claims file and is subject to the provisions of the
Freedom of Information Act and the Privacy Act OPM may disclose this information to support the
disputed claim decision If you file a lawsuit this information will become part of the court record
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Section 5 Benefits
Medical and Surgical Benefits
What is covered A comprehensive range of preventative diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits you pay a 10 copay per primary care
office visit a 10 copay per referral visit and nothing for obstetrical gynecological services performed by
a participating Certified Nurse Midwife Within the Service Area house calls will be provided if in the
judgement of the Plan doctor such care is necessary and appropriate you pay a 10 copay for primary
care physician's house call a 10 copay for referral doctor's house call nothing for home visits by nurses
health aides or therapists
The following services are included
Preventive care including well baby care and periodic check ups
Diagnostic prostate examinations for men age 40 through 75
Mammograms are covered as follows for women age 35 through age 39 one mammogram during
these five years for women age 40 through 49 one mammogram every one or two years for women
age 50 through 64 one mammogram every year and for women age 65 and above one mammogram
every two years 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 including 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 after the first
maternity visit All office visit copayments are waived if services are performed by a participating
Certified Nurse Midwife 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 and family planning services including Norplant implantations injectable
contraceptive drugs and IUD fittings
Chlamydia screening test if you are a a sexually active woman under the age of 20 years b a
woman who is at least 20 years old and has multiple risk factors c a man who has multiple risk
factors
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including test and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart lung single and double lung pancreas kidney and liver transplants
allogeneic donor bone marrow transplants autolugous 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 and advanced non Hodgkin's lymphoma
advanced neuroblastoma testicular mediastinal retroperitoneal and ovarian germ cell tumors breast
cancer multiple myeloma and epithelial ovarian cancer Related medical and hospital expenses of
the donor are covered when the recipient is covered by this Plan
Blood products derivatives and components artificial blood products biological serum and the
administration of the agent Blood products shall include any product which is created from a
component of blood such as but not limited to plasma packed red blood cells platelets albumin
Factor VIII immunoglobulin and prolastin
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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
A breast prosthesis prescribed by a physician if you have undergone a mastectomy and have not had
Reconstructive Breast Surgery
One home visit within twenty four 24 hours after discharge and an additional home visit if
prescribed by your attending physician if you have a mastectomy or a testicle surgically removed
either on an outpatient basis or inpatient and you are hospitalized for less than forty eight 48 hours
Dialysis
Chemotherapy radiation therapy and 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 at no additional cost to you
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 The following treatments for cleft lip and cleft palate are covered when
referred by a primary care physician and approved by the Plan inpatient and outpatient orthodontics oral
surgery and otologic audiological speech language services
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 chiropractic and acupuncture
is provided on an inpatient or outpatient basis for up to sixty 60 consecutive days per acute condition
if significant improvement can be expected within 60 days you pay nothing for sixty 60 treatments
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 All therapy must be referred by a Plan provider and
authorized by the Plan
Diagnosis and treatment of infertility is covered you pay a 10 copay for primary care services
For services of other Plan providers you pay 50 of charges The following types of artificial
insemination are covered intravaginal insemination IVI intercervical insemination ICI and
intrauterine insemination IUI you pay 50 of charges for all related expenses cost of donor sperm is
not covered Other assisted reproductive technology ART procedures such as in vitro fertilization and
embryo transfer are not covered
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infraction is
provided on an inpatient or outpatient basis for up to 60 days per condition
Orthopedic devices such as braces prosthetic devices such as artificial limbs external lenses
following cataract removal breast prostheses surgical bras and durable medical equipment such as
wheelchairs and hospital beds are covered You pay 10 of charges with a maximum benefit of 9,000
per contract year
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What is not Physical examinations that are not necessary for medical reasons such as those required for obtaining covered or continuing employment or insurance attending school or camp or travel
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Transplants not listed as covered
Long term rehabilitative therapy
Hearing aids
Homemaker services
Foot orthotics
Whole blood and concentrated red blood cells not replaced by the member
Routine circumcision
Hospital Benefits 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 for inpatient our outpatient hospital services 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
Extended care Skilled nursing care
The Plan provides a comprehensive range of benefits for up to 120 days per calendar year with no dollar
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 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
Ambulance service
Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
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Limited benefits Inpatient dental procedures
Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need for
hospitalization for reasons totally unrelated to the dental procedures 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
In addition general anesthesia and associated facility charges in conjunction with dental care are covered
for individuals who meet certain criteria as determined by the Plan doctor Services must be preauthorized
by the Plan
Acute inpatient detoxification
Hospitalization for medical treatment of substance abuse is limited to emergency care 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 15 for
nonmedical Substance Abuse Benefits
What is not Personal comfort items such as telephone and television covered Whole blood and concentrated red blood cells not replaced by the member
Custodial care rest cures domiciliary or convalescent care
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you as a emergency prudent layperson 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
Emergencies If you are in an emergency situation please call your primary care physician In extreme emergencies if within the Service you are unable to contact your doctor contact the local emergency system e g the 911 telephone system
Area 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 should 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
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Arnett HMO Health Plan 2000
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 emergency room visit or 15 per visit at Arnett urgent care center visit for emergency care
services that are covered benefits of this Plan If the emergency results in admission to a hospital the
emergency care copay is waived
Emergencies Benefits are available for any medically necessary health service that is immediately required because of outside the injury or unforeseen illness
Service Area 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 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 care services to the extent the services would have been covered if
received from Plan providers
You pay
50 per emergency room visit or 15 per urgent care center visit for emergency care 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
What is not Elective care or nonemergency care covered Emergency care provided outside the Service Area if the need for care could have been foreseen
before departing the Service Area
Medical and hospital costs resulting from a normal full term delivery of a baby outside the
Service Area
Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency care upon non Plan receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form If you are
providers 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
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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 treatment of mental illness or disorders
Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Outpatient care Your plan covers outpatient mental health with a 10 copayment per visit You must obtain a referral from your Primary Care Provider and prior approval by the Plan
Inpatient care Your plan covers inpatient mental health with no dollar or day limit You must obtain a referral from your Primary Care Physician and prior approval by the Plan
What is not Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to covered 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
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
Outpatient care Up to 20 outpatient visits to Plan doctor consultants or other psychiatric personnel each calendar year you pay 20 copay for each covered visit all charges thereafter
Inpatient care
Inpatient care Up to 30 days of hospitalization each calendar year with no copayment per day and all charges after 30 days in a substance abuse treatment plan You must obtain a referral from your Primary Care Physician
and obtain prior approval by the Plan
What is not Treatment that is not authorized by a Plan doctor covered
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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 34 day supply You pay 5 copayment for Generic Drugs and 15 copayment for
formulary Brand Name Drugs and 30 copayment for non formulary Brand Name Drugs If a generic
drug is available and the prescription is filled with a formulary or non formulary Brand Name Drug
member pays the difference in cost in addition to the copayment When you need a prescription filled
present your HMO member card to the pharmacist at a participating pharmacy as listed in the Arnett
HMO Provider Directory
Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary The
Prescription drug formulary is a list of the brand name medication the Plan covers All generic drugs are
covered Medications are chosen for the formulary based on their safety effectiveness and affordability
Non formulary drugs will be covered when prescribed by a Plan doctor at the higher copayment
Covered medications and accessories include
Drugs for which a prescription is required by Federal law
Insulin with a copay charge applied to each visit
Diabetic supplies including insulin syringes needles glucose test tablets and test tape
Benedict's solution or equivalent and acetone test tablets
Disposable needles and syringes needed for injecting covered prescribed medication
Oral contraceptive drugs contraceptive devices
Intravenous fluids and medications for home use implantable drugs such as Norplant some injectable
drugs and diabetic self management training and education services are covered under Medical and
Surgical Benefits
Limited benefits Drugs to treat sexual dysfunction are limited Contact the Plan for dose limits
What is not Drugs available without a prescription or for which there is a nonprescription equivalent available covered
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 except for Clomiphene citrate Clomid
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Dental Care
Accidental injury Restorative services and supplies necessary to promptly repair but not replace sound natural teeth The benefit need for these services must result from an accidental injury occurring while the member is covered under
the Plan Services must be received within 72 hours of the injury You pay a 10 copay per primary care
visit a 10 copay per referral visit a 50 copay per emergency room visit
What is not Other dental services covered
Vision Care
What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of disease of the eye annual eye refractions to provide a written lens prescription for dependents through age 17 may be
obtained from Plan providers You pay nothing
What is not Corrective lenses or frames covered Eye exercises
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
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
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Arnett HMO Health Plan 2000
Section 7 Limitations Rules that affect your benefits
Medicare 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
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 contactyour local Social Security Administration SSA office
or request it from SSA at 1 800 638 6833
When anyone has coverage with us and with another group health plan it is called double 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
Other insurance When you have double coverage one plan is the primary payer it pays benefits first The other plan is coverage 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 tell us that you have double coverage
Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to provide beyond our
them In that case we will make all reasonable efforts to provide you with necessary care
control
When others are When you receive money to compensate you for medical or hospital care for injuries or illness that responsible for another person caused you must reimburse us for whatever services we paid for We will cover the cost
injuries 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
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Arnett HMO Health Plan 2000
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 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 Government Agencies We do not cover services and supplies that a local State or Federal Government agency directly or
indirectly pays for
If you have malpractice claim
If you have a malpractice claim because of services you did or did not receive from a plan provider it
must go to binding arbitration Contact us about how to begin our binding arbitration process
Section 8 FEHB Facts
You have a right OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right to to information information about your health plan its networks providers and facilities You can also find out about care
about your HMO 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 888 448 7440 or write to Arnett HMO P O Box 6108
Lafayette IN 47903 6108 You may also contact us by fax at 765 448 7700 or visit our website at
www arnettplans com
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal information Employees Health Benefits Plans brochures for other plans and other materials you need to make an
about enrolling in informed decision about the FEHB When you may change your enrollment
Program 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
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Arnett HMO Health Plan 2000
When are my The benefits in this brochure are effective on January 1 If you are new to this plan your coverage and benefits and premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants's
premiums premiums begin January 1 effective
What happens When you retire you can usually stay in the FEHB Program Generally you must have been enrolled in when I retire 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 unmarried coverage are
dependent children under age 22 including any foster or step children your employing or retirement office
available for me authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 and my family
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 We will keep your medical and claims information confidential Only the following will have access to it and claims records
OPM this Plan and subcontractors when they administer this contract confidential
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 Form cards
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 you conditions enrolled in this Plan solely because you had the condition before you enrolled
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Arnett HMO Health Plan 2000
When you lose benefits
What happens if You will receive an additional 31 days of coverage for no additional premium when my enrollment in Your enrollment ends unless you cancel your enrollment or
this Plan ends 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 under your spouse coverage 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
Key points about TCC
You 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 TCC You in TCC 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
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How can I You may convert to an individual policy if convert to Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not
individual pay your premium you cannot convert coverage You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is available You
must apply in writing to us within 31 days after you receive this notice However if you are a family
member who is losing coverage the employing or retirement office will not notify you You must apply in
writing to us within 31 days after you are no longer eligible for coverage
Your benefits and rates will differ from those under the FEHB Program however you will not have to
answer questions about your health and we will not impose a waiting period or limit your coverage due to
pre existing conditions
How can I get If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that a Certificate of indicates how long you have been enrolled with us You can use this certificate when getting health
Group Health insurance or other health care coverage You must arrange for the other coverage within 63 days of Plan Coverage 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
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Arnett HMO Health Plan 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 sometimes the problem is a simple error
If the provider does not resolve the matter call us at 765 448 7440 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 N W 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 and 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
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Notes
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Notes
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Arnett HMO Health Plan 2000
Summary of Benefits for Arnett HMO Health Plan 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 Care Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes in hospital doctor care room and board general nursing
care private room and private nursing care if medically necessary
diagnostic tests drugs and medical supplies use of operating room
intensive care and complete maternity care You pay nothing 11
Extended Care All necessary services with 120 days per calendar year You pay nothing 13
Skilled Nursing
Mental Conditions Diagnosis and treatment of acute psychiatric conditions You pay nothing 16
Substance Abuse Up to 30 days per year in a substance abuse treatment program You pay
no copayment per day for the first 30 days and all charges thereafter 16
Outpatient Care Comprehensive range of services such as diagnosis and treatment of 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 a 10 copay per office visit
including any lab tests and x rays done in the office and a 10 copay per
house call by a doctor 11
Home Health Care All necessary visits by nurses and health aides You pay nothing 13
Mental Conditions You pay 10 copay per visit 16
Substance Abuse Up to 20 outpatient visits per year You pay 20 copay per visit 16
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 15 copay for Arnett Urgent Care visits and any charges for services
that are not covered by this Plan 14
Prescription drugs All Generic Drugs up to a 34 day supply 5 copayment
Formulary Brand Name Drugs up to a 34 day supply 15 copayment
Non Formulary Brand Name Drugs up to a 34 day supply 30 copayment
If a generic drug is available and the prescription is filled with a Formulary
or Non Formulary brand name drug member pays the difference in cost in
addition to the copay 17
Dental care Accidental injury benefit you pay nothing 18
Vision Care One annual refraction for dependents through age 17 You pay nothing 18
Out of pocket Your out of pocket expenses for benefits covered under this Plan are limited limit to the copayments which are required for a few benefits
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Arnett HMO Health Plan 2000
2000 Rate Information for
Arnett HMO Health Plan
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 employee who is not
a member of a special postal employment class refer to the category definitions is 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 Gov't Your Gov't Your USPS Your USPS Your Enrollment Code Share Share Share Share Share Share Share Share
Lafayette area
Self Only G21 78.83 27.60 170.80 59.80 93.06 13.37 93.26 13.17
Self and Family G22 175.97 100.78 381.27 218.36 207.74 69.01 201.02 75.73
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