Pages 1--32 from Microsoft Word - 2000brochure.doc

A Health Maintenance Organization

For changes
in benefits
see page 5

Serving St Louis Central Southeast and Southwest Missouri areas and St Clair Madison counties Illinois

Enrollment in this plan is limited see page 6 for requirements
Enrollment code 9G1 Self Only
9G2 Self and Family
This plan has accreditation
from the NCQA See the 2000 Guide
for more information on NCQA

Visit the OPM website at http www opm gov insure

Authorized for distribution by the
UNITED STATES OFFICE OF PERSONNEL MANAGEMENT
RETIREMENT AND INSURANCE SERVICE

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BlueCHOICE HMO 2000
Table of Contents
Introduction 3
Plain language 3
How to use this brochure 4
Section 1 Health Maintenance Organizations 5
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 22
Section 7 Limitations Rules that affect your benefits 23
Section 8 FEHB facts 25
Inspector General Advisory Stop Health Care Fraud 29
Summary of benefits 30
Premiums 32

BlueCHOICE a name HMO Missouri Inc uses to do business and Alliance Blue Cross Blue Shield the name RightCHOICE Managed Care Inc
uses to do business in Missouri are independent licensees of the Blue Cross and Blue Shield Association

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BlueCHOICE HMO 2000
Introduction
HMO Missouri Inc d b a BlueCHOICE 1831 Chestnut Street
St Louis MO 63103 2275
This brochure describes the benefits you can receive from BlueCHOICE HMO under its contract CS2838 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 BlueCHOICE HMO as this Plan throughout this brochure even though in other legal documents you will see a plan
referred to as a carrier

These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year

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BlueCHOICE HMO 2000
How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits
with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make
comparisons easier

1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and
how they work

2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not
to pay for your claim or to deny your request for a service

5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find
information about non FEHB benefits

6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB facts Read this for information about the Federal Employees Health Benefits FEHB Program

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

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

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

Section 2 How We Change For 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary changes care office visits

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

You may review and obtain copies of your medical records on request If you want copies of your medical records ask your health care provider for them You may ask that a physician
amend a record that is not accurate not relevant or incomplete If the physician does not amend
your record you may add a brief statement to it If they do not provide you your records call us
and we will assist you

If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This screening is for colorectal cancer

Changes to Your share of the premium will increase by 5.9 percent for Self Only or 4.9 percent for Self and this Plan Family
In the year 2000 benefits will be based on a calendar year and not on a 365 day period
No referral or authorization is required for an annual well women gynecological exam and other medically necessary OB GYN care received from a BlueCHOICE OB GYN

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BlueCHOICE HMO 2000
Section 3 How to get benefits
What is this To enroll with us you must live in the BlueCHOICE service area or within a 30 mile radius of a Plan's service BlueCHOICE network hospital Our service area is
area The St Louis Area including the Missouri counties of Crawford Franklin Gasconade Jefferson
Lincoln Montgomery Pike St Charles St Francois St Louis City and County Ste Genevieve
Warren and Washington the Central Missouri Area counties of Adair Audrain Boone Callaway
Camden Chariton Cole Cooper Howard Linn Macon Maries Miller Moniteau Monroe
Morgan Osage Phelps Pulaski Putnam Randolph Schuyler Sullivan the Southwest Missouri
Area counties of Barry Barton Cedar Christian Dade Dallas Douglas Greene Hickory Jasper Laclede Lawrence McDonald Newton Ozark Polk Stone Taney Webster Wright and the

Southeast Missouri Area counties of Butler Carter Ripley Wayne
You may also enroll with us if you live in the Illinois counties of Madison or St Clair and work in
Missouri

Ordinarily you must get your care from providers who contract with us If you receive care outside
our service area we will pay only for emergency care We will 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 As a BlueCHOICE member you have access to physician care through
HMO USA a nationwide network of Blue Cross and Blue Shield HMOs HMO USA is one of the
largest HMO networks in the country offering coverage in more than 200 U S cities If you become
ill while visiting one of these cities contact the HMO USA network at 1 800 1 HMO USA This
number is also found on the back of your ID card The HMO USA referral coordinator will schedule
an appointment with an HMO USA physician in the area from which you are calling No office visit
copay will be required and you will not need to file a claim If you or a family member move you do
not have to wait until Open Season to change plans Contact your employment or retirement office

How much do You must share the cost of some services This is called either a copayment a set dollar amount or I pay for coinsurance a set percentage of charges Please remember you must pay this amount when you
services receive services When a member receives an allergy injection flu shot or immunization in the physician's office and no other services are received there is no copayment The regular office visit
copay will continue to apply if any other covered care is received during the visit

After you pay 100 of your annual premium in copayments for one family member or 100 of
your annual premium for two or more family members 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 for your prescription drugs and dental services 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 BlueCHOICE can extend this deadline if you show that
circumstances beyond your control prevented you from filing on time

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BlueCHOICE HMO 2000
Who provides This Plan is an individual practice prepayment Plan All participating doctors practice in their own my health care offices in the community Covered benefits are available only from those doctors and from
participating hospitals and participating pharmacies The Plan arranges with doctors and hospitals to
provide medical care for both the prevention of disease and the treatment of serious illness For the
treatment of rare or unusual medical cases the Plan may provide services without geographic
limitation

You must select a primary care doctor for each covered family member More than 1,000 primary
care physicians participate in BlueCHOICE For most care you must contact your primary care
doctor for a referral or authorization before seeing any other doctor or obtaining specialty care or
hospital services for a nonemergency A wide variety of Board eligible and Board certified
specialists are participating Plan doctors Your Plan primary doctor admits you to a participating
hospital where he she has admitting privileges for elective procedures

What do I do if my Call us We will help you select a new one primary care physician
leaves the Plan
What do I do if I need to Talk to your Plan physician If you need to be hospitalized your primary care physician or specialist go into the hospital will make the necessary hospital arrangements and supervise your care

What do I do if I'm in the First call our customer service department at 1 800 932 4480 If you are new to the FEHB Program hospital when I join this we will arrange for you to receive care If you are currently in the FEHB Program and are switching
Plan 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

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

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

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

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BlueCHOICE HMO 2000
But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to continue serious illness and my seeing your provider for up to 90 days after we notify you that we are terminating our contract with
provider leaves the Plan the provider unless the termination is for cause If you are in the second or third trimester of or this Plan leaves the pregnancy you may continue to see your OB GYN until the end of your postpartum care
Program You may also be able to continue seeing your provider if your plan drops out of the FEHB Program
and you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or
chronic condition or are in your second or third trimester Your new plan will pay for or provide
your care for up to 90 days after you receive notice that your prior plan is leaving the FEHB
Program If you are in your second or third trimester your new plan will pay for the OB GYN care
you receive from your current provider until the end of your postpartum care

How do you authorize Your primary care physician must obtain authorization from BlueCHOICE before admitting you to medical services the hospital or referring you to a nonparticipating provider Before giving approval we consider if
the service is medically necessary and if it follows generally accepted medical practice

How do you decide if a A drug device or biological product is experimental or investigational if the drug device or service is experimental biological product cannot be lawfully marketed without approval of the U S Food and Drug
or investigational Administration FDA and approval for marketing has not been given at the time it is furnished Approval means all forms of acceptance by the FDA

An FDA approved drug device or biological product for use other than its intended purpose and
labeled indications or medical treatment or procedure is experimental or investigational if

1 reliable evidence shows that it is the subject of ongoing phase I II or III clinical trials or under
study to determine its maximum tolerated dose its toxicity its safety or

2 reliable evidence shows that the consensus of opinion among experts regarding the drug device
or biological product or medical treatment or procedure is that further studies or clinical trials
are necessary to determine its maximum tolerated dose its toxicity its safety its efficacy or its
efficacy as compared with the standard means of treatment or diagnosis

Reliable evidence shall mean only published reports and articles in the authorized medical and
scientific literature the written protocol or protocols used by the treating facility or the protocol s of
another facility studying substantially the same drug device or medical treatment or procedure or
the written informed consent used by the treating facility or by another facility studying substantially
the same drug device or medical treatment or procedure

FDA approved drugs devices or biological products used for their intended purpose and labeled
indication and those that have received FDA approval subject to postmarketing approval clinical
trials and devices classified by the FDA as Category B Non experimental Investigational Devices
are not considered experimental or investigational

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BlueCHOICE HMO 2000
Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
Be in writing Refer to specific brochure wording explaining why you believe our decision is wrong and
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
Maintain our denial in writing Pay the claim
Arrange for a health care provider to give you the service or 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 or
a denial request for service
What if I have a serious or Call us at 1 800 932 4480 and we will expedite our review life threatening condition
and you haven't responded to my request
for service
What if you have denied If we expedite your review due to a serious medical condition and deny your claim we will inform my request for care and OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's
my condition is serious or health benefits Contract Division II at 202 606 3818 between 8 a m and 5 p m Serious or lifethreatening life threatening conditions are ones that may cause permanent loss of bodily functions or death if they
are not treated as soon as possible

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

1 We 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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BlueCHOICE HMO 2000
What do I send Your request must be complete or OPM will return it to you You must send the following to OPM information
1 A statement about why you believe our decision is wrong based on specific benefit provisions
in this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills
medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call

If you want OPM to review different claims you must clearly identify which documents apply to
which claim

Who can make the Those who have a legal right to file a disputed claim with OPM are request
1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled
person's representative They must send a copy of the person's specific written consent with the
review request

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

What if OPM OPM's decision is 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 supplies or drugs covered by us until you have completed the OPM review procedure
described above

Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you 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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BlueCHOICE HMO 2000
Section 5 Benefits
Medical 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 charges for laboratory tests and X rays performed in the doctor's office 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 nothing for home visits by nurses and
health aides

The following services are included and are subject to the office copay unless stated otherwise
Preventive care including well baby care and periodic check ups
Allergy injections flu shots and immunizations
For members age 50 and above one screening sigmoidoscopy every five years
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 and above one mammogram every year In addition to routine screening
mammograms are covered when prescribed by the doctor as medically necessary to diagnose or
treat your illness

Benefits will be provided for breast reconstruction surgery following a mastectomy including surgery to produce a symmetrical appearance on the other breast Benefits will be provided for

all stages of breast reconstruction following a mastectomy including treatment of physical
complications including lymphedemas and for breast prostheses including surgical bras and
replacements

Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays you pay a 10 copay for services performed at an outpatient facility

Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor Initial copay applies for maternity care Subsequent copays are
waived per pregnancy The mother at her option may remain in the hospital up to 48 hours
after a regular vaginal delivery and 96 hours after a cesarean delivery Inpatient stays will be
extended if medically necessary If enrollment in the Plan is terminated during pregnancy
benefits will not be provided after coverage under the Plan has ended Ordinary nursery care of
the newborn child during the covered portion of the mother's hospital confinement for maternity
will be covered under either a Self Only or Self and Family enrollment other care of an infant
who requires definitive treatment will be covered only if the infant is covered under a Self and
Family enrollment

Voluntary sterilization and family planning services
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints The cost of the devices is covered except for cochlear implants

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BlueCHOICE HMO 2000
Medical Surgical Benefits continued
What is covered Cornea heart heart lung kidney liver lung single or double and pancreas kidney continued 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 nonHodgkin's
lymphoma advanced neuroblastoma breast cancer multiple myeloma epithelial
ovarian cancer and testicular mediastinal retroperitoneal and ovarian germ cell tumors
Treatment for breast cancer multiple myeloma and epithelial ovarian cancer may be provided
in a non randomized clinical trial Treatment is provided when deemed medically necessary and
appropriate by the Plan's Medical Director and performed in a Plan facility Related medical and
hospital expenses of the donor are covered when the recipient is covered by the 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
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity
Durable medical equipment such as wheelchairs canes walkers and hospital beds will be provided as determined by the Plan to treat a disease or to improve bodily function due to

disease injury or congenital defect The equipment must be prescribed by a participating
physician obtained from a participating durable medical equipment provider and approved in
advance by the Plan You pay appropriate copay per piece of equipment Varying copays apply
to durable medical equipment ranging from 10 to 100 Durable medical equipment benefits
are limited to the rental not to exceed the cost of purchase or at the option of BlueCHOICE
the purchase of equipment duly approved by BlueCHOICE

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 intraoral
areas surrounding the teeth are not covered including any dental care involved in treatment
of temporomandibular 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
Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis for up to two consecutive months per condition if significant improvement

can be expected within two months you pay a 10 copay per outpatient session Speech therapy
is limited to treatment of certain speech impairments of organic origin Occupational therapy is
limited to services that assist the member to achieve and maintain self care and improved
functioning in other activities of daily living

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BlueCHOICE HMO 2000
Medical Surgical Benefits continued
Limited benefits Diagnosis and treatment of infertility are covered you pay nothing Artificial insemination is continued covered you pay nothing The cost of donor sperm is not covered Other assisted reproductive
technology ART procedures such as in vitro fertilization and embryo transfer are not covered
Oral fertility drugs and injectable fertility drugs are not covered under the prescription drug
benefit or medical and surgical benefit

Orthopedic devices such as braces used to treat congenital defects and prosthetic devices such as artificial limbs and lenses following cataract removal are covered

Cardiac Rehabilitation Benefits will be provided for Medically Necessary treatments that are rendered by a Network Provider on an outpatient basis following but not limited to a heart
transplant bypass surgery or a myocardial infarction This benefit is provided for one
consecutive 12 week period per calendar year You pay 10 per session

Pulmonary Rehabilitation Benefits will be provided for Medically Necessary treatments that are rendered by a Network Provider on an outpatient basis limited to a lifetime maximum of 14

sessions per initial 12 month period and one session per three month period thereafter You pay
10 per session

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

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BlueCHOICE HMO 2000
Hospital Extended Care Benefits
What is covered
Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan doctor You pay nothing All necessary services are covered

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

Specialized care units such 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 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

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

Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis detoxification treatment of medical conditions and medical management of withdrawal symptoms acute
detoxification if the Plan doctor determines that outpatient management is not medically
appropriate See page 17 for nonmedical substance abuse benefits

What is not covered Personal comfort items such as telephone and television Blood and blood derivatives not replaced by the member

Custodial care rest cures domiciliary or convalescent care

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BlueCHOICE HMO 2000
Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe emergency endangers your life or could result in serious injury or disability and requires immediate medical or
surgical care
Emergencies within If you are in an emergency situation please call your primary care doctor In extreme emergencies if the service area 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 should notify the
Plan within 48 hours It is your responsibility to ensure that the Plan has been notified in a timely
manner

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

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

You pay 50 per hospital emergency room visit or 10 per emergency care service visit at the Primary Care Physician office or urgent care center for covered services 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 or 10 per emergency care visit for emergency services at the Primary Care Physician office or urgent care center for covered services of this Plan If the
emergency results in admission to a hospital the emergency care copay is waived

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BlueCHOICE 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 covered Elective care or nonemergency care Emergency care provided outside the service area if the need for care could have been foreseen

before leaving the service area
Medical and hospital costs resulting from a normal full term delivery of a baby outside the service area

Filing claims for non Plan With your authorization the Plan will pay benefits directly to the providers of your emergency care providers 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

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BlueCHOICE HMO 2000
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

The medical management of certain 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 Office visits for the medical aspects of treatment do not count toward
the 20 outpatient Mental Conditions visit limit

Outpatient care Up to 20 outpatient visits to Plan doctors consultants or other psychiatric personnel per calendar year you pay the following copays for up to 20 visits
Visits 1 and 2 No copay
Visits 3 10 A 10 copay visit
Visits 11 20 A 25 copay visit
or 50 of the cost of the visit whichever is less

Inpatient care Up to 35 days of hospitalization each calendar year you pay nothing for the first 35 days all charges thereafter

What is not covered Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to significant improvement through relatively short term treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless determined by a Plan doctor to be necessary and appropriate
Psychological testing when not medically necessary to determine the appropriate treatment of a short term psychiatric condition

Substance Abuse
What is covered This Plan provides medical and hospital services such as acute detoxification services for the medical non psychiatric aspects of substance abuse including alcoholism and drug addiction the
same as for any other illness or condition and to the extent shown below the services necessary for
diagnosis and treatment

Outpatient care Up to 20 outpatient visits to Participating Substance Abuse Providers per calendar year you pay the following copays for up to 20 visits
Visits 1 10 15 copay visit
Visits 11 15 5 copay visit
Visits 16 20 No copay
or 50 of the cost of the visit whichever is less

Inpatient care Up to 35 days per calendar year in a substance abuse rehabilitation intermediate care program in an alcohol detoxification or rehabilitation center approved by the Plan you pay a 50 copay per day
during the benefit period all charges thereafter

What is not covered Treatment that is not authorized by a Plan doctor
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

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BlueCHOICE HMO 2000
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 30 day supply or one commercially prepared unit i e one inhaler one vial
ophthalmic medication or insulin Drugs are prescribed by Plan doctors and dispensed in
accordance with BlueCHOICE's drug formulary Nonpreferred brand name drugs will be covered
when prescribed by a Plan doctor The Plan must authorize a nonpreferred brand name drug before it
may be dispensed It is the prescribing doctor's responsibility to obtain the Plan's authorization You
pay a 5 copay per prescription unit or refill for generic drugs 10 for preferred brand name drugs
and 15 for nonpreferred brand name drugs When a generic drug is available but you request the
brand name drug you pay the price difference between the generic and brand name drug as well as
the 5 copay per prescription unit or refill You must present your BlueCHOICE ID card at the
pharmacy in order to be charged only the retail prescription drug benefit copay In addition mailorder
drugs and out of area emergency drugs are available as follows

Retail 30 day supply Mail Order 90 day supply 5 generic 10 generic
10 preferred brand name 20 preferred brand name
15 nonpreferred brand name 30 nonpreferred brand name

Out of Area Emergency Prescriptions 25 copay
Covered medications and accessories include
Drugs for which a prescription is required by law FDA approved prescription drugs and devices for birth control

Insulin with a copay charge applied to each vial Disposable needles and syringes needed to inject covered prescribed medication including
insulin
Diabetic test strips lancets Intravenous fluids and medication for home use provided under home health services at no

charge and some injectable drugs are covered under Medical and Surgical Benefits
Limited Drug Benefits Prescription benefits for the treatment of sexual dysfunction will only be available with prior
authorization where sexual dysfunction is secondary to a medical condition and the medical history
and work up is documented You must receive prior authorization before receiving any prescription
for the treatment of sexual dysfunction If approved four prescribed treatments per month will be
available and subject to the nonpreferred brand name copayment

What is not covered Drugs for which there is a nonprescription equivalent available Drugs obtained at a non Plan pharmacy except for out of area emergencies An out of area
emergency is defined as being beyond a 50 mile radius of the member's participating pharmacy
Reimbursement for prescriptions purchased out of area in the event of an emergency will be
the cost of the prescription less a 25 copayment

Vitamins and nutritional substances that can be purchased without a prescription Medical equipment devices and supplies such as dressings and antiseptics

Drugs for cosmetic purposes Drugs to enhance athletic performance
Test agents and devices Fertility drugs Oral or Injectable
Prescription smoking cessation aids

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BlueCHOICE HMO 2000
Other Benefits
Dental care
What is covered The following dental services are covered when provided by your participating Plan primary dentist you pay a 5 copay per office visit
Preventive dental care as follows
Office visit for oral examination limited to two visits per calendar year Oral prophylaxis cleaning as necessary limited to two visits per calendar year

Topical application of fluorides is limited to two courses of treatment per calendar year limited to children under age 18
Oral hygiene instruction Dietary advice and counseling
Consultations with Primary Dentist
What is not covered Other dental services not shown as covered
Vision care
What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of
the eye annual eye refractions to provide a written lens prescription for eyeglasses may be
obtained from Plan providers In addition the Plan provides up to 35 reimbursement per 24 month
period for corrective eyeglasses and frames or contact lenses hard or soft lenses You pay a 10
copay per visit

What is not covered Eye exercises

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BlueCHOICE 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 and any charges for these services do not count toward any FEHB deductibles out of pocket
maximum copay charges etc These benefits are not subject to FEHB disputed claims procedures

Eat Smart Learn to eat right and control your weight You'll get 75 if you achieve your weight loss goal through a participating facility

Breathe Easy Smoking cessation classes offered in cooperation with local health care providers teach you some helpful tips for kicking the habit Earn 50 for regular class attendance and for quitting smoking

Physical Fitness If you are 18 or older we will reimburse you 25 of annual dues up to 100 for continued attendance at the health club of your choice
Self Help Educational Free literature is available on a variety of subjects including stress alcohol drugs and cholesterol Information

Take the First Step When you read the HealthChoices brochures you are on your way to a healthier happier you Call the BlueCHOICE Client Service department today to get the brochures for the above items that
interest you

Away From Home Care BlueCHOICE offers its members medical care in urgent situations when traveling outside of the service area
Also members who are traveling for an extended time or who are on an extended work assignment
in another city may be eligible to apply for a guest membership in a local Blue Cross and Blue
Shield HMO The guest membership also temporarily covers dependent children who are away at
school or living in another city

Blue Horizons Medicare This plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare without HMO formerly payment of an FEHB premium As indicated on page 23 certain annuitants and former spouses who
BlueCHOICE Senior are covered by both Medicare Parts A and B and FEHB may elect to drop their FEHB coverage and later reenroll in FEHB Contact your retirement system for information on changing your FEHB
enrollment Contact us at 314 923 6500 or 1 800 652 6387 for information on the Medicare prepaid
plan BlueHorizons and the cost of enrolling in this program

RightSteps This is a voluntary program that strives to help mothers to be avoid potential problems during pregnancy Members who have primary health coverage through BlueCHOICE are eligible to enroll
Pregnant women who choose to participate must enroll in RightSteps within 20 weeks of becoming
pregnant Participants will then be asked to complete a questionnaire An obstetrical registered nurse
will then contact the member periodically to provide information on pregnancy and childbirth We
will encourage the member to have early regular prenatal care and to pay attention to her lifestyle
behaviors Mothers to be who participate in the program will also receive a nationally recognized
book on pregnancy childbirth and infant care up to a 40 reimbursement for the cost of a childbirth
or parenting class and a special gift from us after the baby arrives

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BlueCHOICE HMO 2000
TAKE CHARGE TM Our goal is to help our members who have asthma manage their disease more successfully Working of Your Asthma with the patient's physician we provide case management services to severe asthmatics through
frequent phone calls individual care plans home health visits as approved by the patient's doctor
durable medical equipment benefits and asthma educational material Adults and children with mild
or moderate asthma receive asthma educational materials as requested

CardioCall TM BlueCHOICE also offers a service based on studies that show telephone management and education can reduce the risks associated with heart attacks CardioCall uses an automated telephone system to
call members at risk for heart attacks and who voluntarily enroll in the program These members
receive six telephone calls over six months Each call is confidential and takes only five to 10
minutes After each call the member receives a personalized letter recapping the information
reviewed during the call and educational information The member's doctor also receives a copy of
each report

Note Special programs such as RightSteps Take Charge of Your Asthma and
CardioCall are voluntary programs that are available to members who have primary health
coverage through BlueCHOICE

BlueCHOICE Client Service Department
1 800 932 4480 or
TDD 314 923 6299

Benefits on these pages are not part of the FEHB contract

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BlueCHOICE 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 Services drugs or supplies that are not medically necessary following Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits
Experimental or investigational procedures treatments drugs or devices Procedures services drugs and supplies related to abortions except when the life of the mother
would be endangered if the fetus were carried to term or when the pregnancy is the result of an
act of rape or incest

Procedures services drugs and supplies related to sex transformations Services or supplies you receive from a provider or facility barred from the FEHB Program and

Expenses you incurred while you were not enrolled in this Plan

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

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

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

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

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

For information on Medicare Choice plans contact your local Social Security Administration SSA
office or request it from SSA at 1 800 638 6833 For information on the Medicare Choice plan
offered by this Plan see page 20 for information about BlueHorizons Medicare HMO

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

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

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

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

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

TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you we are the
primary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE
coverage

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BlueCHOICE HMO 2000
Workers compensation
We do not cover You need because of a workplace related disease or injury that the Office of Workers services that Compensation Programs OWCP or a similar Federal or State agency determine they must
provide
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws

Once the OWCP or similar agency has paid its maximum benefits for your treatment we will
provide your benefits

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

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

If you want specific information about us call 1 800 932 4480 or write to BlueCHOICE 1831
Chestnut Street St Louis MO 63103

Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal information about Employees Health Benefits Plans brochures for other plans and other materials you need to make an
enrolling in the FEHB informed decision about 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 benefits and The benefits in this brochure are effective on January 1 If you are new to this plan your coverage premiums effective and premiums begin on the first day of your first pay period that starts on or after January 1
Annuitants premiums begin January 1

What happens when I When you retire you can usually stay in the FEHB Program Generally you must have been 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 coverage Self Only coverage is for you alone Self and Family coverage is for you your spouse and your are available for my unmarried dependent children under age 22 including any foster or step children your employing or
family and me retirement office authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years of age or older who is incapable of self support

If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry
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

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BlueCHOICE HMO 2000
Are my medical and We will keep your medical and claims information confidential Only the following will have access claims records to it
confidential OPM this Plan and subcontractors when they administer this contract
This plan and appropriate third parties such as other insurance plans and the Office of Workers Compensation Programs OWCP when coordinating benefit payments and
subrogating claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions

OPM and the General Accounting Office when conducting audits Individuals involved in bona fide medical research or education that does not disclose your
identity or
OPM when reviewing a disputed claim or defending litigation about a claim

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

What if I paid a Your old plan's deductible continues until our coverage begins deductible under
my old plan
Pre existing conditions We will not refuse to cover the treatment of a condition that you or a family member had before you enrolled in this Plan solely because you had the condition before you enrolled

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

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

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

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

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BlueCHOICE HMO 2000
Key points about TCC
You can pick a new plan If you leave Federal service you can receive TCC for up to 18 months after you separate

If you no longer qualify as a family member you can receive TCC for up to 36 months Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32 nd day after your regular coverage ends even if several months have passed
You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll in TCC If you leave Federal service your employing office will notify you of your right to enroll under TCC You must enroll within 60 days of leaving or receiving this notice whichever is later

Children You must notify your employing or retirement office within 60 days after your child is no
longer an eligible family member That office will send you information about enrolling in TCC
You must enroll your child within 60 days after 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 to You may convert to an individual policy if 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

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

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BlueCHOICE HMO 2000
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that Certificate of Group indicates how long you have been enrolled with us You can use this certificate when getting health
Health Plan Coverage insurance or other health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions
for health related conditions based on the information in the certificate

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

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BlueCHOICE 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 1 800 932 4480 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

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BlueCHOICE HMO 2000
Summary of Benefits for BlueCHOICE 2000
Do not rely on this chart alone This chart merely summarizes certain important expenses covered by the Plan This is only a brief
summary of benefits 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 14

Extended All necessary services no dollar or day limit You pay nothing 14 Care

Mental Diagnosis and treatment of acute psychiatric conditions for up to 35 days Conditions of inpatient care per calendar year You pay nothing 17
Substance Up to 35 days per year in a substance abuse treatment program You pay Abuse 50 per day up to 35 days all charges thereafter 17
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 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 20 outpatient visits per year You pay the following copays per Conditions outpatient visit
Visits 1 and 2 No copay
Visits 3 10 A 10 copay visit
Visits 11 20 A 25 copay visit
or 50 of the cost of the visit whichever is less 17

Substance Up to 20 outpatient visits per year You pay the following copays per Abuse outpatient visit
Visits 1 10 A 15 copay visit
Visits 11 15 A 5 copay visit
Visits 16 20 No copay
or 50 of the cost of the visit whichever is less 17

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BlueCHOICE HMO 2000
Benefits Plan pays provides Page
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 10 copay at Primary Care Physicians

offices and urgent care centers You pay a 50 copay at the hospital for
each emergency room visit and any charges for services that are not
covered by this Plan 15

Prescription drugs Drugs must be prescribed by a Plan doctor and obtained at a Plan pharmacy You pay the following copays depending how where you
purchase your prescription drugs Retail 30 day supply 5 10 15 for
generic preferred brand and nonpreferred brand respectively Mail Order
90 day supply 10 20 30 for generic preferred brand and nonpreferred
brand respectively Emergency out of area 25 copay 18

Dental care Preventive dental care you pay a 5 copay per visit 19
Vision care One refraction annually You pay 10 copay per visit The Plan pays up to 35 for eyeglasses or contact lenses per 24 month period 19

Out of pocket Copayments are required for a few benefits however after your out ofpocket expenses reach a maximum of 100 of annual premium per Self
Only 100 of annual premium for Self and Family enrollment per
calendar year covered benefits will be provided at 100 This copay
maximum does not include prescription drugs 18

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BlueCHOICE HMO 2000
2000 Rate Information for

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

StLouis Central SW Poplar Bluff area
Self Only 9G1 78.83 32.69 170.80 70.83 93.06 18.46 93.26 18.26
Self and Family 9G2 175.97 65.47 381.27 141.85 207.74 33.70 201.02 40.42

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