Pages 1--24 from 99-346-Federal FEHB Contract

Capital District Physicians Health Plan Inc 2000
A Health Maintenance Organization

For changesin benefitssee
page
2

Serving The Capital District NY area Enrollment in this Plan is limited see page 3 for requirements
Enrollment code SG1 Self Only
SG2 Self and Family

This Plan has commendable accreditation from the NCQA See the 2000 Guide
for more information on NCQA

Visit the OPM website at httpwwwopmgovinsure and
this plans website at httpwwwcdphpcom

Authorized for distribution by the
United States Office of
Personnel Management
Retirement and Insurance Service
RI73 549 1
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Table of Contents
Introduction 1
Plain language 1
How to use this brochure 1
Section 1 Health Maintenance Organizations 2
Section 2 How we change for 2000 2
Section 3 How to get benefits 3
Section 4 What to do if we deny your claim or request for service 5
Section 5 Benefits 7
Section 6 General exclusionsThings we dont cover 15
Section 7 LimitationsRules that affect your benefits 15
Section 8 FEHB Facts 16
Inspector General Advisory Stop Healthcare Fraud 19
Summary of benefits 21
Rate Information 22

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Introduction
Capital District Physicians Health Plan 17 Columbia Circle Albany NY 12203

This brochure describes the benefits you can receive from Capital District Physicians Health Plan Inc under its contract CS 2612 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 2 Premiums are listed at the end of this brochure

Plain Language
The President and Vice President are making the Governments 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 Capital District Physicians Health Plan Inc 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 rewritten the Benefits section of this brochure You will find new benefits language next year

How To Use This Brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plans 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 nonFEHB benefits
6 General exclusions Things we dont 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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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 wellbaby 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 plans 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 andor
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
Programwide changes To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary care office visits

This year you have a right to more information about this Plan care management our networks facilities and providers
If you have a chronic or disabling condition and your provider leaves the Plan at our request you may continue to see your specialist for up to 90 days If your provider leaves the Plan and you are in the second
or third trimester of pregnancy you may be able to continue seeing your OBGYN until the end of your postpartum care You have similar rights if this Plan leaves the FEHB program See Section 3 How to
get benefits for more information
You may review and obtain copies of your medical records on request If you want copies of your medical records ask your health care provider for them You may ask that a physician amend a record that is not

accurate not relevant or incomplete If the physician does not amend your record you may add a brief statement to it If they do not provide you your records call us and we will assist you

If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This screening is for colorectal cancer
Changes to this Plan Your share of the nonpostal premium will increase by 103 for Self Only or 105 for Self and Family
The office visit copay for primary care physicians specialists and specialist consultations have increased from 800 to 1000 copay See Page 7

House call visit copays has increased from 800 to 1000 See Page 7
Diabetic supplies have increased from 800 or 20 coinsurance to 1000 or 20 coinsurance whichever is less See Page 13

The copay has increased from 800 to 1000 for the following covered services
Diabetic education management program visits See Page 8
Diagnosis and treatment of diseases of eye See Page 7
Routine vision exam See Page 13
Dental care for accidental injury See Page 13
Outpatient physical therapy occupational and speech therapy visits See Page 8
Allergy testing and treatment See Page 7
Voluntary sterilization and family planning services See Page 7
Chiropractic care visits See Page 8
Cancer second opinion See Page 8
Dialysis treatment See Page 8
Diagnosis and treatment of infertility See Page 9
Artificial insemination services See Page 9
Cardiac rehabilitation outpatient visits See Page 9
Diagnostic Procedures See Page 8
Chemotherapy radiation therapy and inhalation therapy See Page 8
Blood blood product See Page 8
Transfusion services See Page 8
Home health care See Page 8

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Section 3 How to get benefits
What is this Plans To enroll with us you must live or work in our service area This is where our providers practice Our service area service area is the New York counties of Albany Columbia Fulton Greene Montgomery Rensselaer
Saratoga Schenectady Schoharie Warren and Washington
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 or services that have received prior approval from the
Plan 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 you should consider enrolling in a feeforservice plan or an HMO that has
agreements with affiliates in other areas If you or a family member move you do not have to wait until Open Season to change plans Contact your employing or retirement office

How much do You must share the cost of some services This is called either a copayment a set dollar amount or coinsurance I pay for services a set percentage of charges Please remember you must pay this amount when you receive services
Do I have to You normally wont have to submit claims to us unless you receive emergency services from a provider submit claims who doesnt 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 The Capital District Physicians Health Plan Inc provides medical care through participating providers in my health care their private offices area hospitals and other health care facilities

The first and most important decision each member must make is the selection of a primary care doctor The decision is important since it is through this doctor that all other health services particularly those of
specialists are obtained When you enroll you will be asked to let the Plan know which primary care doctors you have selected for you and each of your family members In addition female members may also select
an obstetriciangynecologist The Plans provider directory lists primary care doctors general practitioners family practitioners pediatricians and internists with their locations and phone numbers and notes
whether or not the doctor is accepting new patients Directories are updated on a regular basis and are available at the time of enrollment or by calling the Member Services Department at 5188623747 If you
need help choosing a doctor call the Plan You may change your doctor selection by notifying the Plan thirty 30 days in advance

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 Talk to your Plan physician If you need to be hospitalized your primary care physician or specialist will to go into the hospital make the necessary hospital arrangements and supervise your care Your Primary Care Physician is

required to obtain the necessary authorizations for hospitalizations
What do I do if Im First call our customer service department at 5188623747 or 18007772273 If you are new to the FEHB in the hospital when Program we will arrange for you to receive care If you are currently in the FEHB Program and are switching

I join this 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

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Section 3 How to get benefits continued
How do I get Your primary care physician will arrange your referral to a specialist Except in a medical emergency or specialty care when a primary care doctor has designated another doctor to see patients when he or she is unavailable
you must receive a referral from your primary care doctor before seeing any other doctor or obtaining special services Referrals to a participating specialist are given at the primary care doctors discretion if
specialists or consultants are required beyond those participating in the Plan the primary care doctor will make arrangements for appropriate referrals

On referrals the primary care doctor will give specific instructions to the specialist as to what services are authorized If additional services or visits are suggested you must first check with your primary care doctor
Do not go to the specialist unless your primary care doctor has arranged for and the Plan has issued an authorization for the referral in advance Areferral is not required for emergency care obstetriciangynecologist
of record or a routine eye exam once every 24 months
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 Such a treatment plan must be approved by CDPHP in consultation with the Members
Primary Care Physician the specialist if any and the member or the members designee
What do I do if I am Your primary care physician will decide what treatment you need If they decide to refer you to a specialist seeing a specialist ask if you can see your current specialist If your current specialist does not participate with us you must

when I enroll 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

New members may continue an ongoing course of treatment with a current nonparticipating provider for a transitional period This transitional care is covered if the member has a lifethreatening or degenerative
and disabling disease or condition for a transitional period of up to sixty days from the effective date of enrollment If the member has entered the second trimester of pregnancy at the effective date of enrollment
the transitional period shall include postpartum care directly related to the delivery Note This transitional care will be authorized by CDPHP only if the nonparticipating provider agrees to accept the Plans
established rates as full payment adheres to the Plans quality assurance requirements provides the Plan with medical information related to the care and adheres to the Plans policies and procedures In addition
transitional coverage is only available for those services as stated in the Federal brochure subject to the described limitations

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 If you are currently receiving care from a provider who is leaving the CDPHP network of participating
providers you may continue an ongoing course of treatment with that provider during a transitional period The transitional period shall continue for up to ninety 90 days from the date of notice to you If you

have entered the second trimester of pregnancy at the time the provider leaves the CDPHP network the transitional period includes the provision of postpartum care directly related to the delivery

The transitional care will be authorized by CDPHP only if the provider agrees to adhere to the Plans quality assurance requirements provides the Plan with medical information related to the care and adheres
to the Plans policies and procedures Transitional care is not authorized if your provider has left the CDPHP network for reasons involving imminent harm to patient care a determination of fraud or a final
disciplinary action by a state licensing board or other governmental agency that impairs the providers ability to practice In addition transitional coverage is for those services as stated in the Federal brochure
and subject to the described limitations

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Section 3 How to get benefits continued
But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to continue seeing serious illness and my your provider for up to 90 days after we notify you that we are terminating our contract with the provider
provider leaves the unless the termination is for cause If you are in the second or third trimester of pregnancy you may Plan or this Plan continue to see your OBGYN until the end of your postpartum care
leaves the Program You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and
you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic condition or are in your second or third trimester Your new plan will pay for or provide your care for up

to 90 days after you receive notice that your prior plan is leaving the FEHB Program If you are in your second or third trimester your new plan will pay for the OBGYN care you receive from your current
provider until the end of your postpartum care
How do you authorize Your physician must get our approval before sending you to a hospital referring you to a specialist or medical services recommending followup care 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 The Plan will only cover experimental and investigational treatment if the Plan determines that the service is experimental proposed treatment has proven to be safe and efficient for a particular illness injury or disease through

or investigational nationally recognized clinical trials and if an expert panel has reviewed the proposed treatment and deemed it appropriate Procedure must be approved by the Federal Food and Drug Administration andor
the National Institute of Health Technology Assessment

Section 4 What to do if we deny your claim or request for service
If we deny services or wont pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing 2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were unable to make a timely request due to reasons beyond your control

We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing 2 Pay the claim
3 Arrange for a health care provider to give you the service or 4 Ask for more information

If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30 days after we receive the additional information If we do not receive the requested
information within 60 days we will make our decision based on the information we already have
When may I ask OPM You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal OPM will to review a denial determine if we correctly applied the terms of our contract when we denied your claim or request for service

What if I have a serious or life threatening condition and you havent responded to my request for service
Call us at 518 8623747 or 18007772273 and we will expedite our review
What if you have denied my request for care and my condition is serious or life threatening
If we expedite your review due to a serious medical condition and deny your claim we will inform OPM so that they can give your claim expedited treatment too Alternately you can call OPMs health benefits
Contract Division III at 202 6060755 between 8 am and 5 pm Serious or lifethreatening conditions are ones that may cause permanent loss of bodily functions or death if they are not treated as soon as possible

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Section 4 What to do if we deny your claim or request for service continued
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 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
What do I send to OPM Your request must be complete or OPM will return it to you You must send the following information
1 A statement about why you believe our decision is wrong based on specific benefit provisions in this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim 4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to which claim
Who can make Those who have a legal right to file a disputed claim with OPM are the request
1 Anyone enrolled in the Plan 2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled persons representative They must send a copy of the persons specific written consent with the review request

Where should I mail Send your request for review to Office of Personnel Management Office of Insurance Programs my disputed claim Contract Division III PO Box 436 Washington DC 20044
OPMs decision is final There are no other administrative appeals If OPM agrees with our decision your only recourse is to sue
If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services or supplies
What laws apply if Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its review I file a lawsuit 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 us to the Privacy Act 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 preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits and outpatient hospital visits you pay an
1000 office visit or outpatient hospital visit copay but no copay for laboratory tests provided in Plan designated laboratory radiology network XRay ambulatory surgical facilities 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 an 1000 copay for a doctors house call and nothing for home visits by nurses and health aides

Well child visits to primary care doctor are covered in full for the following visits by 1 month 2 months 4 months 6 months 9 months 12 months 15 months 18 months ages 219 one visityear
The following services are included and are subject to the office visit copay unless stated otherwise
Annual adult nongynecological routine exam is covered in full
Extended coverage for fulltime students up to age 22 who are attending school outside of the Plans service area These services must be medically necessary services and cannot wait until the student
returns to the service area For these services care must be preauthorized by calling 18002742332
Routine immunizations and boosters covered in full
Mammograms are covered in full 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
Consultations by specialists
Diagnostic procedures such as laboratory tests and Xrays covered in full at network facilities
Voluntary sterilization and family planning services
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor Copays are waived for maternity care Maternity care coverage including parent
education assistance and training in breast or bottle feeding and the performance of any necessary maternal and newborn clinical assessments for member and newborn for at least fortyeight hours
after childbirth for any delivery other than a caesarean section and at least ninetysix hours following a caesarean section The member shall have the option to be discharged earlier than the fortyeight or
ninetysix hours In such cases one home care visit which may be requested at any time within forty eight hours of the time of delivery ninetysix hours in the case of caesarean section shall be delivered
within twentyfour hours a after discharge or b of the time of the mothers request whichever is later Any such home care is covered in full Newborn and Infant Nursery Care for at least fortyeight hours
after childbirth for any delivery other than a caesarean section 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 mothers 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

Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including test and treatment materials such as allergy serum You pay nothing for the allergy serum

The insertion of internal prosthetic devices such as pacemakers and artificial joints

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Section 5 Benefits continued
Nonexperimental transplants including cornea heart heartlung kidney liver lung single and double and pancreas 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 nonlymphocytic leukemia advanced Hodgkins lymphoma advanced nonHodgkins
lymphoma advanced neuroblastoma breast cancer multiple myeloma epithelial ovarian cancer and testicular mediastinal retroperitoneal and ovarian germ cell tumors Related medical and hospital
expenses of the donor are covered
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
Chiropractic care for medically necessary spinal manipulation when referred by primary care physician
Cancer diagnosis may receive a second opinion from a participating or nonparticipating provider with a referral from members primary care physician

Blood and blood products
Transfusion services including storage for autologous donations of blood and blood components when associated with a scheduled surgical procedure

Surgical treatment of morbid obesity
Diabetic selfmanagement training and diet education are covered for insulin dependent persons
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 covered in full
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 members 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
Shortterm rehabilitative therapy 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 an 1000 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 selfcare and improved functioning in other activities of daily living
Shortterm rehabilitative physical therapy is provided on an inpatient basis for up to two consecutive months per condition if significant improvement can be expected or on an outpatient basis for up to 120 days per
condition if significant improvement can be expected you pay an 1000 copay per outpatient session

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Section 5 Benefits continued
Diagnosis and treatment of infertility is covered you pay 1000 The following types of artificial insemination are covered intravaginal insemination IVI intracervical insemination ICI and intrauterine
insemination IUI you pay 1000 cost of donor sperm is not covered Fertility drugs are covered under the Prescription Drug Benefits Other assisted reproductive technology ART procedures such as in
vitro fertilization and embryo transfer are not covered
Cardiac rehabilitation is covered for the therapeutic or rehabilitative phase of cardiac rehabilitation provided within three 3 months following a heart transplant cardiac bypass surgery cardiac valvular surgery
angioplasty or a myocardial infarction for one 1 program per member per calendar year for up to thirty six 36 sessions you pay an 1000 copay per session

Orthopedic devices such as braces you pay 20 of charges Prosthetic devices such as artificial limbs and lenses following cataract removal breast prostheses and surgical bras following mastectomies as well as
their replacement you pay 20 of charges Durable medical equipment such as wheelchairs and hospital beds you pay 20 of charges Copayments also apply to any repair or replacement of parts and must be
approved by your primary care doctor through the Plans Medical Director
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 surgicallyinduced sterility
Surgery primarily for cosmetic purposes
Homemaker services
Storage of blood and blood derivatives except in the case of autologous blood donations required for a scheduled surgical procedure

Hearing aids
Longterm rehabilitative therapy
Routine foot care and foot orthotics

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 up to 90 days per calendar year when fulltime 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

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Section 5 Benefits continued
Hospice Care Supportive and palliative care for a terminally ill member is covered for a total of two hundred and ten 210 days 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 and determined to be medically necessary
Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need for procedures 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 treatment detoxification 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 14 for nonmedical substance abuse benefits

What is not covered Personal comfort items such as telephone and television
Storage of blood and blood products except in the case of autologous blood donations required for a scheduled surgical procedure

Custodial care rest cures domiciliary or convalescent care
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 Some problems are emergencies because if not treated promptly they might become more serious examples include deep cuts and broken bones Others are emergencies because they are potentially life
threatening such as heart attacks strokes poisonings gunshot wounds or sudden inability to breathe There are many other acute conditions that the Plan may determine are medical emergencies what they
all have in common is the need for quick action
Emergencies within If you are in an emergency situation as described above contact the local emergency system eg the 911 the Service Area 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 within 48 hours unless it was not reasonably possible to do so It is your responsibility to ensure that the Plan has been timely notified

If you are unsure whether your condition is an emergency contact your primary care physician for assistance and guidance before seeking emergency care Your primary care physician or a physician covering for
your primary care physician is required to be on call 24 hours a day However if you believe you need immediate medical attention go to the nearest hospital emergency room or call the local emergency
response access number
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 nonPlan 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 nonPlan 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 followup care recommended by nonPlan providers must be approved by the Plan or provided by Plan providers

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Section 5 Benefits continued
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers

You pay 5000 per hospital emergency room visit or 2500 per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital the emergency
room copay is waived
Emergencies outside Benefits are available for any medically necessary health service that is immediately required because of the Service Area 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 would be transferred when medically feasible with any ambulance charges covered in full

To be covered by this Plan any followup care recommended by nonPlan 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 5000 per hospital emergency room visit or 2500 per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital the
emergency room copay is waived
What is covered Emergency care at a doctors office or an urgent care center
Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service determined by the Plan to be medically necessary

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 fullterm 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 nonPlan providers 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 Plans decision you may request reconsideration in accordance with the disputed claims procedure described on page 5

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

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Section 5 Benefits continued
Outpatient care Up to 20 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year you pay a 1000 copay for each covered visit Member is responsible for all charges thereafter

Inpatient care Up to 60 days hospitalization each calendar year you pay a 10500 copay per day for the first 60 days Member is responsible for 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 shortterm treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless determined by a Plan doctor to be necessary and appropriate
Psychological testing that is not medically necessary to determine the appropriate treatment of a short term psychiatric condition

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 60 outpatient visits to Plan providers for treatment each calendar year you pay nothing for each covered visitall charges thereafter On a Self and Family enrollment up to twenty 20 visits of the sixty
60 visits may be used for family therapy related to alcoholism alcohol abuse or substance abuse by a covered family member

Inpatient care Up to 30 days of substance abuse rehabilitation intermediate care per calendar year in a participating alcohol detoxification or rehabilitation center approved by the Plan you pay nothing during the benefit
period Member is responsible for all charges thereafter
What is not covered Treatment that is not authorized by a Plan doctor

Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 30day supply You pay a 500 copay per prescription unit or refill for generic drugs and a
1000 copay per prescription unit or refill for name brand drugs Drugs are prescribed by Plan doctors and dispensed in accordance with the Plans drug formulary Nonformulary drugs will be covered when
prescribed by a Plan doctor
CDPHP approved maintenance drugs for chronic conditions can be ordered through the mail You pay two copayments for a 90 day supply

Covered medications and accessories include
Drugs for which a prescription is required by Federal law
All FDA approved contraceptive drugs and devices
Selfadministered injectable drugs you pay 5 for covered generic 10 for covered brand name
Implanted timerelease medications such as Norplant For Norplant you pay a 20 coinsurance There is no charge when the device is implanted during a covered hospitalization There will be no refund of
any portion of these copays if the implanted timerelease medication is removed before the end of its expected life

Durable medical equipment for insulin dependent persons Preauthorization from the Plans Medical Director is required for items such as injection aids appurtenances and insulin infusion devices data
management systems such as blood and glucose monitors for the legally blind you pay an 1000 copay
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Section 5 Benefits continued
Insulin oral agents to control blood sugar syringes needles test strips lancets and visual reading and urine test strips you pay 20 or 1000 copay whichever is less Cartridges are covered for the
legally blind you pay 20 or 1000 copay whichever is less
Nutritional supplements for the therapeutic treatment of phenylketonuria PKU
Smoking cessation drugs and medication including prescription nicotine patches Members must complete a smoking cessation class Classes are provided free to members

Infertility drugs you pay 5 for covered generic 10 for covered brand name
Disposable needles and syringes needed for injecting covered prescribed medication you pay 20 copay

Intravenous fluids and medication for home use implantable drugs and some injectable drugs are covered under Medical and Surgical Benefits you pay 5 generic 10 name brand covered under
Medical and Surgical Benefits as a home health service see page 9
Prescription drugs for certain inherited diseases of amino acid and organic acid metabolism shall include modified solid food products that are low protein or which contain modified protein which
are medically necessary and such coverage for any continuous period of 12 months for any member shall not exceed 2500 You pay 5 copay for prescription generic and 10 copay for prescription
name brand
What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available
Drugs obtained at a nonPlan pharmacy except for outofarea 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
Contraceptive devices except diaphragms
Drugs prescribed by a dentist
Weight Loss Drugs

Other Benefits
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 You pay an 1000 copay per visit

Vision Care
What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye eye refractions to provide a written lens prescription for eyeglasses are covered once every
twentyfour 24 months and may be obtained from Plan providers You pay a 1000 copay per visit
What is not covered Corrective lenses or frames
Eye exercises

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

Wellness Programs CDPHP conducts several wellness programs on a quarterly basis Programs are free of charge to members and are held throughout the Capital Region Programs are announced in the member
newsletter Smart Moves Programs include smoking cessation child rearing nutrition and fitness

Care Wise CareWise is a 24hour nurse hotline that CDPHP members can call and ask medical questions
Wellness Discounts CDPHP members receive discounts on safety equipment memberships to local fitness clubs and weight control centers See the CDPHP Wellness Discount Brochure for listings of participating
facilities

Benefits on this page are not part of the FEHB contract
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Section 6 General exclusions Things we dont 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 Services drugs or supplies that are not medically necessary the following Services not required according to accepted standards of medical dental or psychiatric practice

Care by nonPlan providers except for authorized referrals or emergencies see Emergency Benefits Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest
Procedures services drugs and supplies related to sex transformations Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan

Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On occasion you may
need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a MedicareChoice 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 MedicareChoice plan contact your retirement office If you later want to reenroll 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 MedicareChoice 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 MedicareChoice plans contact your local Social Security Administration SSA office or request it from SSA at 18006386833

Other group When anyone has coverage with us and with another group health plan it is called double coverage You insurance coverage 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 Under certain extraordinary circumstances we may have to delay your services or be unable to provide beyond our control 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 another responsible for injuries 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

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Section 7 Limitations Rules that affect your benefits continued
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you we are the primary payer
See your TRICARE Health Benefits Advisor if you have questions about TRICARE coverage

Workers compensation
We do not cover You need because of a workplacerelated disease or injury that the Office of Workers Compensation services that 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

If you have a If you have a provider complaint because of services you did or did not receive from a plan provider provider complaint Contact the Plans Member Advocate at 5188623747 or by mail to Capital District Physicians Health
Plan Inc 17 Columbia Circle Albany NY 12203

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 right to information about information about your health plan its networks providers and facilities You can also find out about
your HMO care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPMs website wwwopmgov lists the
specific types of information that we must make available to you

If you want specific information about us call 5188623747 or 18007772273 or write to Capital District Physicians Health Plan Inc 17 Columbia Circle Albany NY 12203 You may also contact us
by fax at 5188629395 or visit our website at wwwcdphpcom
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal Employees information about Health Benefits Plans brochures for other plans and other materials you need to make an informed

enrolling in the decision about FEHB Program
When you may change your enrollment How you can cover your family members

What happens when you transfer to another Federal agency go on leave without pay enter military service or retire
When your enrollment ends and The next Open Season for enrollment

We dont determine who is eligible for coverage and in most cases cannot change your enrollment status without information from your employing or retirement office
When are my The benefits in this brochure are effective on January 1 If you are new to this plan your coverage and benefits and premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants
premiums effective premiums begin January 1
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

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Section 8 FEHB FACTS continued
What types of coverage SelfOnly coverage is for you alone Self and Family coverage is for you your spouse and your unmarried are available for dependent children under age 22 including any foster or step children your employing or retirement office
my family and me 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 selfsupport

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

Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits nor will we Please tell us immediately when you add or remove family members
from your coverage for any reason including divorce
If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled in another FEHB plan

Are my medical and We will keep your medical and claims information confidential Only the following will have access to it claims records
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 andor 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 SF2809 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 plans deductible continues until our coverage begins deductible under

my old plan
Preexisting 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 enrollment in this Plan ends
You will receive an additional 31 days of coverage for no additional premium when
Your enrollment ends unless you cancel your enrollment or You are a family member no longer eligible for coverage

You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits under your spouse coverage former spouses 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 exspouses 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 7927 which describes TCC
and the RI 705 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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Section 8 FEHB FACTS continued
Key points about TCC You can pick a new plan If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32nd day after your regular coverage ends even if several months have passed
You pay the total premium and generally a 2percent administrative charge The government does not share your costs
You receive another 31day 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 in TCC You must enroll within 60 days of leaving or receiving this notice whichever is later

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

Divorce Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about enrolling in TCC Your former spouse must enroll within 60 days after the event which qualifies them for coverage or
receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notifies your employing or retirement office within the 60day 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 preexisting conditions
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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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 5188623747 or 18007772273 and explain the situation
If we do not resolve the issue call or write
THE HEALTH CARE FRAUD HOTLINE 2024183300

US Office of Personnel Management Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400 Washington DC 20415

Penalties for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud Also the Inspector General may
investigate anyone who uses an ID 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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Summary of Benefits for Capital District Physicians Health Plan Inc 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 paysprovides Page
Inpatient care Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes inhospital doctor care room and board general nursing care
private room and private nursing care if medially necessary diagnostic tests drugs and medical supplies use of operating room intensive care and
complete maternity care You pay nothing 9

Extended Care All necessary services up to 90 days per calendar year You pay nothing 9
Mental Conditions Diagnosis and treatment of acute psychiatric conditions for up to 60 days of inpatient care per year You pay a 10500 per day copay 11

Substance Abuse Up to 30 days of substance abuse treatment per year You pay nothing 12
Outpatient Care Comprehensive range of services such as diagnosis and treatment of illness or injury care including specialists care You pay a 1000 per office visit
or per outpatient hospital visit 1000 per house call by a doctor Preventive care including wellbaby care annual adult exam and routine immunizations
laboratory tests and Xrays complete maternity care covered in full 7

Home Health Care All necessary visits by nurses and health aids You pay nothing 8
Mental Conditions Up to 20 outpatient visits per year You pay a 1000 copay per visit 11
Substance Abuse Up to 60 outpatient visits per year You pay nothing per visit 12
Emergency Care Reasonable charges for services and supplies required because of a medical emergency You pay a 5000 copay to the hospital for each emergency room
visit or 2500 per urgent care center visit and any charges for services that are not covered by this Plan 10

Prescription Drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 500 per prescription unit or refill for generic drugs and
1000 per prescription unit of refill for name brand drugs injectable drugs and implanted timerelease medications 12

Dental Care Accidental injury benefit you pay a 1000 per visit 13
Vision Care One refraction every twentyfour 24 months You pay 1000 per visit 13
Outofpocket limit Your outofpocket expenses for services covered under the Plan are limited to the stated copayments and coinsurance which are required
for a few benefits 3

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2000 Rate Information for Capital District Physicians Health Plan
NonPostal rates apply to most nonPostal 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 US 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 702 to determine which rate applies to you

Postal rates do not apply to noncareer 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

NonPostal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Govt Your Govt Your USPS Your USPS Your
Enrollment Code Share Share Share Share Share Share Share Share

Capital District area
Self Only SG1 6227 2076 13493 4497 7369 934 7369 934
Self and Family SG2 15980 5326 34622 11541 18909 2397 18909 2397

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