Pages 1--36 from Untitled

Altius Health Plans 2000 Formerly PacifiCare of Utah
A Health Maintenance Organization

For changes in benefits
see page 5

Serving Parts of Utah along the Wasatch Front
Enrollment in this Plan is limited see page 6 for details
Enrollment code 9K1 Self Only
9K2 Self and Family

Visit the OPM website at http www opm gov insure and
this Plan's website at http www altiushealthplans com

Authorized for distribution by the
United States Office of
Personnel Management

RI 73 564 1
1 Page 2 3

Table of Contents PAGE
Introduction 2
Plain language 2
How to use this brochure 3
Section 1 Health Maintenance Organizations 4
Section 2 How we change for 2000 5
Section 3 How to get benefits 6
Section 4 What to do if we deny your claim or request for service 9
Section 5 Benefits 11
Section 6 General exclusions Things we don't cover 24
Section 7 Limitations Rules that affect your benefits 25
Section 8 FEHB facts 27
Inspector General Advisory Stop Healthcare Fraud 31
Summary of benefits Inside Back Cover
Premiums Back Cover 2
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Altius Health Plans 2000
Introduction
Altius Health Plans 10421 South Jordan Gateway
Suite 400 South Jordan Utah 84095

This brochure describes the benefits you can receive from Altius Health Plans HMO under its contract CS2839 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 Altius Health Plans 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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Altius Health Plans 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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Altius Health Plans 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and other providers that contract with us These providers coordinate your health care services The care you receive includes preventive
care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury
When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay the copayments and coinsurance listed in this brochure When you receive emergency services you may have to submit claim forms

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

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Altius Health Plans 2000
Section 2 How we change for 2000
Program wide This year you have a right to more information about this Plan care management our networks facilities changes and providers

If you have a chronic or disabling condition and your provider leaves the Plan at our request you may continue to see your specialist for up to 90 days If your provider leaves the Plan and you are in the
second or third trimester of pregnancy you may be able to continue seeing your OB GYN until the end of your postpartum care You have similar rights if this Plan leaves the FEHB program See Section 3 How
To Get Benefits for more information
You may review and obtain copies of your medical records on request If you want copies of your medical records ask your health care provider for them You may ask that a physician amend a record
that is not accurate not relevant or incomplete If the physician does not amend your record you may add a brief statement to it If they do not provide you your records call us and we will assist you

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

Changes to this Plan Your share of the premium will increase by 76 6 for Self Only or 59 4 for Self and Family Your share of the Non Postal biweekly premium will increase by 16.54 for Self Only or 30.31 for Self
and Family The Non postal monthly premium will increase by 35.84 for Self Only or 65.66 for Self and Family Your share of the Postal A biweekly premium will increase by 14.19 for Self
Only or 26.62 for Self and Family The postal B biweekly premium will increase by 13.99 for Self Only or 33.34 for Self and Family

Under the Hospital Extended Care Benefits provision hospital copay of 100 per admission is now required
Copayments for prescription drugs increased from 5 copay for generic formulary 10 copay for name brand formulary 25 copay for non formulary to 10 copay for generic formulary 15 copay
for name brand formulary 30 for non formulary
Emergency Room services increased from a 40 copay to a 50 copay within the service area and 100 copay outside the service area

Plan's out of pocket maximum changed from 1,000 for one family member 2,500 for two or more family members to 2,000 for one family member 4,000 for two or more family members

Plan name changed from PacifiCare of Utah to Altius Health Plans

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Altius Health Plans 2000
Section 3 How to get benefits
What is this To enroll with us you must live or work in Box Elder Weber Morgan Davis Salt Lake Summit Tooele Plan's service Utah Wasatch Juab or Sanpete counties This is where our providers practice Our service area is identified
area by the following Zip Codes
84003 84004 84006 84010 84011 84013 84018 84020 84022 84024 84025 84029 84032 84033 84036 84037 84040 84044 84047 84049 84050 84054 84062 84065 84067 84071 84074 84075 84080 84082

84084 84087 84088 84090 84095 84097 84098 84100 84101 84128 84131 84145 84147 84148 84150 84153 84157 84158 84165 84170 84171 84180 84184 84185 84189 84190 84201 84244 84301 84302
84306 84307 84309 84317 84324 84330 84337 84400 84409 84412 84414 84601 84606 84626 84628 84629 84632 84633 84639 84645 84648 84651 84653 84655 84660 84663 84664

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 or urgently needed 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 If you or a family member move you do not have to wait until Open Season to change plans Contact your employing or
retirement office

How much do I You must share the cost of some services This is called either a copayment a set dollar amount or coinsurance pay for services a set percentage of charges Please remember you must pay this amount when you receive services except for
when you have reached the Plan's out of pocket maximum for the calendar year

After you pay 2,000 in copayments or coinsurance for one family member or 4,000 for two or more family members you do not have to make any further payments for certain services for the rest of the calendar year
This is called a catastrophic limit However copayments or coinsurance for your prescription drugs dental services services that are not covered benefits under the Plan and Durable Medical Equipment DME 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 provider who submit claims doesn't contract with us If you file a claim please send us all of the documents for your claim as soon as
possible You must submit claims by December 31 of the year after the year you received the service Either OPM or we can extend this deadline if you show that circumstances beyond your control prevented you from

filing on time

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Altius Health Plans 2000
Section 3 How to get benefits continued
Who provides All members must select a Primary Care Physician or PCP from the Plans Participating Provider Directory my health care Your PCP should practice one of the following disciplines General Practice Family Medicine Internal
Medicine Obstetrics Gynecology OB GYN or Pediatrics Choosing a PCP is very important to Plan members because the PCP provides the coordination of all medical care including referrals and authorizations
for surgery visits to specialists hospitalization durable medical equipment and other services Each family member may choose a different Primary Care Physician Locations and telephone numbers of Plan providers
are listed in the Altius Provider Directory or can be obtained by calling the Customer Service Department at 801 323 6200 or 1 800 377 4161

What do I do if Call us We will help you select a new one my primary
care physician leaves the Plan

What do I do if I Talk to your Plan Physician If you need to be hospitalized your Primary Care Physician or specialist will make need to go into the necessary hospital arrangements and supervise your care
the hospital

What do I do if First call our Customer Service Department at 801 323 6200 or 1 800 377 4161 If you are new to the FEHB I'm in the Program we will arrange for you to receive care If you are currently in the FEHB Program and are switching to
hospital when I us your former Plan will pay for the hospital stay until join this Plan
You are discharged not merely moved to an alternative care center or The day your benefits from your former Plan run out or

The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized

How do I get Your Primary Care Physician will arrange your referral to a specialist In the course of treatment your Altius specialty care contracting Primary Care Physician PCP may refer you to a contracted Altius Specialist You should verify
that the Specialist is contracted and that appropriate referrals have been obtained before you receive 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 Your Primary Care Physician will decide what treatment you need If they decide to refer you to a specialist am seeing a ask if you can see your current specialist If your current specialist does not participate with us you must
specialist when receive treatment from a specialist who does Generally we will not pay for you to see a specialist who does I enroll not participate with our Plan

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

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Altius Health Plans 2000
Section 3 How to get benefits continued
But what if I Please contact us if you believe your condition is chronic or disabling You may be able to continue seeing your have a serious provider for up to 90 days after we notify you that we are terminating our contract with the provider unless the
illness and my termination is for cause If you are in the second or third trimester of pregnancy you may continue to see your provider leaves OB GYN until the end of your postpartum care
the Plan or this You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and you Plan leaves the
enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic condition or Program are in your second or third trimester Your new plan will pay for or provide your care for up to 90 days after

you receive notice that your prior plan is leaving the FEHB Program If you are in your second or third trimester your new plan will pay for the OB GYN care you receive from your current provider until the end of
your postpartum care

How do you Your physician must get our approval before sending you to a hospital referring you to a specialist or authorize recommending follow up care Before giving approval we consider if the service is medically necessary and if
medical it follows generally accepted medical practice services

How do you The Plan accepts the determination of Altius's Medical Management Committee as to whether treatments decide if a procedures and drugs are accepted as no longer experimental or investigational The determinations are based
service is on the safety and efficacy of new medical procedures technologies devices and drugs experimental or
investigational

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Altius Health Plans 2000
Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing 2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were unable to make a timely request due to reasons beyond your control

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

If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30 days after we receive the additional information If we do not receive the requested information within 60 days we will make our
decision based on the information we already have

When may I ask You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal OPM OPM to review a will determine if we correctly applied the terms of our contract when we denied your claim or request for
denial service

What if I have a Call us at 801 323 6200 or 1 800 377 4161 and we will expedite our review serious or life
threatening condition and you haven't
responded to my request for service

What if you have If we expedite your review due to a serious medical condition and deny your claim we will inform OPM denied my request for so that they can give your claim expedited treatment too Alternatively you can call OPM's health
care and my benefits Contract Division II at 202 606 3818 between 8 a m and 5 p m Serious or life threatening condition is serious or conditions are ones that may cause permanent loss of bodily functions or death if they are not treated as
life threatening soon as possible

Are there other time You must write to OPM and ask them to review our decision within 90 days after we uphold our initial 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

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Altius Health Plans 2000
Section 4 What to do if we deny your claim or request for service continued
What do I send to Your request must be complete or OPM will return it to you You must send the following information OPM
1 A statement about why you believe our decision is wrong based on specific benefit provisions in this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills medical records and Explanation of Benefits EOB forms
3 Copies of all letters you sent us about the claim 4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to which claim

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

What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our decision upholds the Plan's your only recourse is to sue
denial If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third year
after the year in which you received the disputed services or supplies

What laws apply if I Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its 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 the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and us to 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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Altius Health Plans 2000
Section 5 BENEFITS
Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits you pay a 10 office visit copay and no
additional copay for laboratory tests and X rays performed during the same office visit 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 nothing for a doctor's house call or for visits by nurses and health aides
The following services are included and are subject to the office visit copay unless stated otherwise

Preventive care including well baby care and periodic checkups Mammograms are covered as follows and not subject to a copay for women age 35 through age 39
one mammogram during this five year period for women age 40 through 49 one mammogram every one or two years for women age 50 through 64 one mammogram every year and for women age 65
and above one mammogram every two years In addition to routine screening mammograms are covered when prescribed by the doctor as medically necessary to diagnose or treat your illness

Routine immunizations and boosters Consultations by specialists

Diagnostic procedures such as laboratory tests and X rays Complete obstetrical maternity care for all covered females including prenatal delivery and
postnatal care by a Plan Provider The mother at her option may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery Inpatient stays will be extended
if medically necessary If enrollment in the Plan is terminated during pregnancy benefits will not be provided after coverage under the Plan has ended Ordinary nursery care of the newborn child during
the covered portion of the mother's hospital confinement for maternity will be covered under either a Self Only or Self and Family enrollment other care of an infant who requires definitive treatment
will be covered only if the infant is covered under a Self and Family enrollment
Voluntary family planning services Implanted contraceptive devices such as Norplant

IUD's 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 are not subject
to a copay
Cornea heart heart lung kidney liver lung single or double and pancreas transplants allogeneic donor bone marrow transplants autologous bone marrow transplants autologous stem cell and

peripheral stem cell support for acute lymphocytic or non lymphocytic leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma advanced neuroblastoma breast cancer
multiple myeloma epithelial ovarian cancer and testicular mediastinal retroperitoneal and ovarian germ cell tumors Treatment for breast cancer multiple myeloma and epithelial ovarian cancer may
be provided in a non randomized clinical trial when treatment is provided in an NCI or NIH approved clinical trial at a Plan designated center of excellence and if approved by the Plan's
medical director in accordance with the Plan's protocols Related medical and hospital expenses of the donor are covered when the recipient is covered by this Plan not subject to a copay for inpatient
hospital care

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11 12
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Altius Health Plans 2000
Section 5 BENEFITS continued
What is covered Women who undergo mastectomies may at their option have this procedure performed on an continued inpatient basis and remain in the hospital up to 48 hours after the procedure The hospital stay is not
subject to a copay Dialysis

Chemotherapy radiation therapy and inhalation therapy Surgical treatment of morbid obesity
Home health services of nurses and health aides including intravenous fluids and medications when prescribed by your Plan doctor who will periodically review the program for continuing
appropriateness and need All necessary medical care in a hospital or extended care facility from Plan doctors and other Plan
providers at no additional cost to you
Blood and blood products are not subject to a copay

Limited benefits Oral and maxillofacial surgery is provided for non dental and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical procedures occurring within or adjacent to the
oral cavity or sinuses including but not limited to treatment of fractures and excision of tumors and cysts All other procedures involving the teeth or intra oral areas surrounding the teeth are not covered
including any dental care involved in treatment of temporomandibular joint TMJ syndrome
Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from an injury or surgery that has produced a major effect on the member's appearance and if the
condition can reasonably be expected to be corrected by such surgery A patient and her attending physician may decide whether to have breast reconstruction surgery following a mastectomy and whether
surgery on the other breast is needed to produce a symmetrical appearance
Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis for up to two 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 function in other activities of daily living
Diagnosis and treatment of infertility is covered you pay 50 of charges The following types of artificial insemination are covered intravaginal insemination IVI intracervical insemination ICI and
intrauterine insemination IUI you pay 50 of charges cost of donor sperm is not covered Fertility drugs other than Clomiphene are not covered Clomiphene is covered under the Prescription Drug
Benefit Other assisted reproductive technology ART procedures such as in vitro fertilization and embryo transfer are not covered

Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is provided at a Plan facility for up to 12 weeks for Phase II and Phase III combined when specific clinical
indications are met You pay a 10 copay per visit
Durable Medical Equipment Medically necessary DME such as contact lenses post cataract removal corrective appliances orthopedic braces artificial aids and prosthetic devices including breast
prostheses and surgical bras and replacements You pay 50 of charges

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 12 13
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Altius Health Plans 2000
Section 5 BENEFITS continued
What is not Physical examinations that are not necessary for medical reasons such as those required for covered obtaining or continuing employment or insurance attending school or camp or travel
Reversal of voluntarily induced sterility Transplants not listed as covered

Surgery primarily for cosmetic purposes Hearing aids
Chiropractic services Homemaker services
Orthopedic devices such as foot orthotics Long term rehabilitative therapy

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 a 100 copay per admission 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 for up to 30 days per calendar year when full time skilled nursing care is necessary and confinement in a skilled nursing facility is in lieu of
hospitalization You pay nothing All necessary services are covered including

Bed board and general nursing care Drugs biologicals supplies and equipment ordinarily provided or arranged for by a skilled nursing
facility when prescribed by a Plan doctor Blood and blood products

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 care Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor You pay a 50 copay

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 13 14
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Altius Health Plans 2000
Section 5 BENEFITS continued
Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need procedures 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 16 for substance abuse benefits

What is not covered Personal comfort items such as telephone and television Custodial care rest cures domiciliary or convalescent care

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 14 15
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Altius Health Plans 2000
Section 5 BENEFITS continued
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 please call your Primary Care Physician In extreme emergencies the service area if you are unable to contact your Primary Care Physician 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 It is your responsibility to pay

for any non emergency services you receive in the emergency room or non urgent care you receive in the urgent care center

If you are hospitalized in non Plan facilities and Plan doctors believe care can be better provided in a Plan hospital you will be transferred when medically feasible with any ambulance charges covered in
full
Benefits are available for care from non Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death disability or significant jeopardy to your condition

To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or provided by Plan providers

Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay A 50 copay per hospital emergency room visit or 10 copay per urgent care visit at a contracted Plan provider facility or office visit for emergency services which are covered benefits of this Plan If the
emergency results in admission to a hospital the emergency 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 will be transferred when medically feasible with any ambulance charges covered in full

To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or provided by Plan providers

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Altius Health Plans 2000
Section 5 BENEFITS continued
Emergencies outside the service area
continued
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers

You pay A 100 copay per hospital emergency room visit or 10 copay per urgent care visit at a contracted Plan provider facility or office visit for emergency services which are covered benefits of this Plan If the
emergency results in admission to a hospital the emergency copay is waived

What is covered Emergency care at a doctor's office or an urgent care center Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service approved by the Plan

What is not covered Elective care or non emergency care Emergency care provided outside the service area if the need for care could have been foreseen
before leaving the service area

Filing claims for nonPlan 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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Altius Health Plans 2000
Section 5 BENEFITS continued
Mental Conditions Substance Abuse Benefits
Mental conditions
What is covered To the extent shown below this Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions including the treatment of mental illness or disorders

Diagnostic evaluation Psychological testing
Psychiatric treatment including individual and group therapy Hospitalization including inpatient professional services

Outpatient care Up to 30 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year you pay a 10 copay for each covered visit you pay all charges thereafter
Inpatient care Up to 30 days of hospitalization each calendar year you pay nothing for the first 30 days you pay all charges thereafter

What is not covered Care for psychiatric conditions which 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 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 nonpsychiatric 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 Unlimited outpatient visits per calendar year to Plan providers for treatment you pay a 10 copay for each covered visit
Inpatient care Up to 30 days per calendar year for substance abuse rehabilitation intermediate care programs in an alcohol detoxification or rehabilitation center approved by the Plan you pay nothing during the benefit
period all charges thereafter No yearly limit for detoxification

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

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 17 18
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Altius Health Plans 2000
Section 5 BENEFITS continued
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 Creams liquids inhalers and suppositories are dispensed in
quantities reflected by standard package size or quantity Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary A formulary is a list of drugs covered by the

Plan and this list is updated on a regular basis The Plan's formulary is determined by reviewing pertinent medical literature provider feedback and changes improvements in medical technology A copy of this
Plan's current drug formulary is available by contacting the Plan
You pay a 10 copayment for generic formulary drugs or a 15 copayment for name brand formulary drugs per prescription unit or refill

Non formulary drugs will be covered when prescribed by a Plan doctor You pay a 30 copayment per prescription unit or refill
Mail order service Up to a 90 day supply of maintenance medications may be obtained through mail order for the cost of one copayment For information on the mail order drug benefit contact Express Scripts Value Rx at 1
800 698 0149 Maintenance Medications are any prescription that is recommended by the Food Drug Administration FDA to be taken on a daily basis Examples include but are not limited to medications
for blood pressure asthma antidepressants cholesterol anticoagulants diabetes hormone replacement and birth control Examples of non maintenance medications include antihistamines antibiotics pain
management muscle relaxants anti migraine medications for sleep or anxiety acne preparations topical cream and ointments

COVERED MEDICATIONS AND ACCESSORIES INCLUDE
Drugs for which a prescription is required by law Oral and injectable contraceptives drugs contraceptive diaphragms and IUD's
FDA approved prescription drugs and devices for birth control Insulin with a copay charge applied to each vial
Diabetic supplies including insulin syringes needles glucose test strips 50 strips per prescription unit and lancets
Intravenous fluids and medication for home use implantable drugs and some injectable drugs such as Depo Provera are covered under Medical Benefits
Clomiphene for infertility Depo Provera an injectable is covered under the Medical and Surgical Benefit at a 10 office visit
copay Disposable needles and syringes needed for injecting covered prescribed medication
Drugs to treat sexual dysfunction when medically necessary limited to six pills per month You pay 50 of the cost of the medication per prescription unit or refill

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 18 19
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Altius Health Plans 2000
Section 5 BENEFITS continued
Prescription Drug Benefits continued
What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent Drugs obtained at a non Plan pharmacy except for out of the area emergencies
Vitamins and nutritional substances which can be purchased without a prescription Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes Drugs to enhance athletic performance
Smoking cessation drugs and medication including nicotine patches Implanted time release medications other than Norplant
Infertility drugs with the exception of Clomiphene Skin patches for motion sickness Transderm Scop
Anorexiants antiobesity agents Progesterone suppositories and capsules
Vaccinations for foreign travel

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 19 20
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Altius Health Plans 2000
Section 5 BENEFITS continued
Other Benefits
Dental care
What is covered The following dental services are covered when provided by participating Primary Care Plan dentists
Preventive diagnostic You Pay Initial examination including full series x rays Nothing

Recall examinations including bite wing x rays Nothing Single films Nothing
Prophylaxis and fluoride treatment child Nothing Prophylaxis adult Nothing
Preventive education Nothing
Emergency treatment Palliative during office hours 14
After hours or as provided by the Altius dentist on call 53
Restorative Routine fillings Amalgam or Composite for permanent or primary teeth
For each filling 1 surface Amalgam 13
Anterior composite 19 2 surfaces Amalgam 19
2 Anterior composite 33 3 surfaces Amalgam 25
Anterior composite 51 4 surfaces Amalgam 39
Stainless steel crown 58
Periodontics Deep scaling root planing and curettage per quadrant 77
Periodontal consultation 41 Gingevectomy per quadrant 120
Muco osseous surgery per quadrant 270 Gingivectomy per tooth to three teeth 20

Oral surgery Extractions routine 1st tooth 32
each additional tooth 26 Impacted teeth soft tissue 59
Impacted teeth partial bony 88 Impacted teeth full bony 122

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 20 21
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Altius Health Plans 2000
Section 5 BENEFITS continued
Other Benefits continued
Dental care
What is covered Endodontics You Pay continued Pulp cap 18
Vital pulpotomy 27 Root Canal Single canal 108
Two canals 131 Three canals 161

Crowns bridges Crown build up with pins 30
Preformed post and build up 51 Porcelain fused to metal crown per unit 266
Cast crown 336
Removable dentures Complete denture upper or lower 375
Partial denture cast frame 419 Teeth clasp extra per unit 36
Stayplates 150 Repairs full or partial dentures simple or involved teeth each 34
Relines per denture 126
Preventive orthodontics Space maintainer unilateral 47
Lingual holding arch 50 Habit breaking appliance 90

Plan Maximum No annual or lifetime maximum limit
Plan pays up to 50 for emergency services required when member is over 100 miles from home and a Plan dentist is not available You pay all charges thereafter

Accidental injury Restorative services and supplies necessary to promptly repair but not replace sound natural teeth are benefit
covered The need for these services must result from an accidental injury you pay nothing

What is not Other dental services not shown as covered covered

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 21 22
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Altius Health Plans 2000
Section 5 BENEFITS continued
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 which include the written lens prescription may be obtained from Plan
providers You pay a 10 copay per visit

What is not Eye exercises covered
Corrective lenses or frames

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 22 23
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Altius Health Plans 2000
Section 5 BENEFITS continued Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB 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 any
charges for these services do not count toward any FEHB deductibles or out of pocket maximums These benefits are not subject to the FEHB disputed claims procedure

Altius is pleased to provide our members with value added benefits during 2000
Optical Discounts Members can receive from 10 to 30 savings on eyewear including contact lenses sunglasses and prescription eyeglasses from
contracted Altius Optical Providers

Lasik Vision Eye Surgery Permanent solutions to vision problems are now available to all Altius members through the Moran Eye Institute at the University of
Utah The Moran Eye Institute is an expert in Lasik surgery and ophthamological services The Moran Eye Institute may be able to provide the vision solutions you're looking for at a 10 discounted price For more information on services call the University of
Utah physician referral line at 1 800 662 0052

Optional Enhanced Dental Coverage Altius offers you a dental option to enhance your basic Federal dental coverage By paying an annual premium which can be billed to
you by the Plan your basic dental coverage would be expanded for the following dental services Restorative Periodontics Oral surgery Endodontics Crown Bridges and Dentures

The monthly cost to you would be Self only 10.13 Family 26.10 Additional copay may be necessary if services of a Dental Specialist are necessary
To enroll in this dental option check your Altius informational packet for detailed benefit information on the enhanced dental package or call the Customer Service Department at 1 800 377 4161
Note Enrollment in the Enhanced Dental is limited to open season This dental package is optional You are not required to enroll in the Enhanced Dental to join the regular Altius FEHB

Vitamins Minerals and Nutritional Supplements Thanks to an exclusive agreement with Earth's Pharmacy Altius members can now get quality vitamins and minerals at significantly
discounted prices The Earth's Pharmacy Physician Formula line of products include formulations for stress management antioxidants sleep energy immunity and many others For a complete catalogue and price list call 1 888 562 9891 Or you can
order from the web site at http www epphysiciansformula com Orders are shipped on or before the following business day by priority mail

Hearing Aids If you're ready to hear what you've been missing consider a high quality hearing aid from Beltone These state of the art hearing aids
are smaller and less noticeable than ever before and available at significant discounts for Altius members For more information call Beltone at 1 800 BEL TONE

Smoking Cessation The decision to quit smoking is one of the best and also the toughest decisions many people make Yet thanks to recent advances
in technology and programs more people than ever are breaking this deadly habit Altius members have two ways to quit Express Scripts Value Rx offers an 18 discount on CQ Nicoderm patches You can also participate in a personalized stop smoking program
called Committed Quitters To receive an order form for the patches and information on the personalized program call the Altius Customer Service Department at 1 800 377 4161

BENEFITS ON THIS PAGE ARE NOT PART OF THE FEHB CONTRACT 23 24
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Altius Health Plans 2000
Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition

We do not cover the following
Services drugs or supplies that are not medically necessary Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan doctors or hospitals 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 when the pregnancy is the result of an act of rape or incest or to prevent the birth of a child that would be
born with grave defects 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 covered by this Plan

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Altius Health Plans 2000
Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On occasion you may need to
file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice Plan and also remain enrolled with us
If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a Medicare Choice Plan when one is available in your area For information on suspending your FEHB enrollment and changing to a
Medicare Choice Plan contact your retirement office If you later want to re enroll in the FEHB Program generally you may do so only at the next Open Season

If you involuntarily lose coverage or move out of the Medicare Choice service area you may re enroll in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice Plans contact your local Social Security Administration SSA office or request it from SSA at 1 800 638 6833

Other group When anyone has coverage with us and with another group health plan it is called double coverage You must insurance tell us if you or a family member has double coverage You must also send us documents about other insurance
coverage 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 them In beyond our that case we will make all reasonable efforts to provide you with necessary care
control

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Altius Health Plans 2000
Section 7 Limitations Rules that affect your benefits continued
When others When you receive money to compensate you for medical or hospital care for injuries or illness that another are responsible person caused you must reimburse us for whatever services we paid for We will cover the cost of treatment
for injuries that exceeds the amount you received in the settlement If you do not seek damages you must agree to let us try This is called subrogation If you need more information contact us for our subrogation procedures

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

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

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

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

If you have a If you have a malpractice claim because of services you did or did not receive from a plan provider it must go to malpractice binding arbitration Contact us about how to begin our binding arbitration process
claim

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Altius Health Plans 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 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 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 our Customer Service Department at 801 323 6200 or 1 800 377 4161 or write to Altius Health Plans 10421 South Jordan Parkway Suite 400 South Jordan
Utah 84095 You may also contact us by fax at 801 933 3639 or visit our website at www altiushealthplans com

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 informed decision about FEHB Program
When you may change your enrollment How you can cover your family members

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

We don't determine who is eligible for coverage and in most cases cannot change your enrollment status without information from your employing or retirement office

When are my benefits The benefits in this brochure are effective on January 1 If you are new to this plan your coverage and and premiums premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants
effective premiums begin January 1

What happens when When you retire you can usually stay in the FEHB Program Generally you must have been enrolled in 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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Altius Health Plans 2000
Section 8 FEHB FACTS continued
What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and your coverage are unmarried dependent children under age 22 including any foster or step children your employing or
available for me and retirement office authorizes coverage for Under certain circumstances you may also get coverage for a my family disabled child 22 years of age or older who is incapable of self support

If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry give birth or add a child to your family You may change your enrollment 31 days before to 60 days after you
give birth or add the child to your family The benefits and premiums for your Self and Family enrollment begin on the first day of the pay period in which the child is born or becomes an eligible
family member
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits nor will we Please tell us immediately when you add or remove family members
from your coverage for any reason including divorce
If you or one of your family members is enrolled in one FEHB Plan that person may not be enrolled in another FEHB Plan

Are my medical and We will keep your medical and claims information confidential Only the following will have access to claims records it
confidential OPM this Plan and subcontractors when they administer this contract
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 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 plan's deductible continues until our coverage begins deductible under my
old Plan

Pre existing We will not refuse to cover the treatment of a condition that you or a family member had before you conditions enrolled in this Plan solely because you had the condition before you enrolled

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Altius Health Plans 2000
Section 8 FEHB FACTS continued
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 If you are divorced from a Federal employee or annuitant you may not continue to get benefits under spouse coverage your former spouse's enrollment But you may be eligible for your own FEHB coverage under the
spouse equity law If you are recently divorced or are anticipating a divorce contact your ex spouse's employing or retirement office to get more information about your coverage choices

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

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

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

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Altius Health Plans 2000
Section 8 FEHB FACTS continued
How do I enroll in If you leave Federal service your employing office will notify you of your right to enroll under TCC You TCC must enroll within 60 days of leaving or receiving this notice whichever is later

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

Former spouses You or your former spouse must notify your employing or retirement office within 60 days of one of these qualifying events
Divorce Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about enrolling in TCC Your former spouse must enroll within 60 days after the event which qualifies them for
coverage or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify your employing or retirement office within the 60 day deadline

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

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 insurance or other health care coverage You must arrange for the other coverage within 63 days of Coverage leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions for
health related conditions based on the information in the certificate

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

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Altius Health Plans 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 801 323 6200 or 1 800 377 4161 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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Altius Health Plans 2000
NOTES

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Altius Health Plans 2000
NOTES

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Altius Health Plans 2000
Summary of Benefits for Altius 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or change

your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY CARE ARE
COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS

Benefits Plan pays provides Page
Inpatient Hospital Comprehensive range of medical and surgical services with no dollar or day limit Includes inhospital care 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 100 copay per admission plan pays 100 thereafter 13
Extended care All necessary services up to 30 consecutive days per calendar year You pay nothing 13

Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per conditions year You pay nothing 17
Substance Each member is entitled to a 30 day per calendar year substance abuse program Abuse You pay nothing no limit for detoxification 17
Outpatient Comprehensive range of services such as diagnosis and treatment of illness or injury including care specialist's care preventive care including well baby care periodic check ups and routine
immunizations laboratory tests and X rays complete maternity care You pay 10 copay per office visit 11

Home Health All necessary visits by nurses and home health aides You pay nothing 12 care
Mental Up to 30 outpatient visits per year You pay 10 copay per visit 17 conditions

Substance Unlimited outpatient visits per year You pay 10 copay per visit 17 Abuse
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay 50 copay to the hospital for each emergency room visit in area a 100 copay to the
hospital for each emergency room visit out of area and a 10 copay for Urgent Care Centers and any charges for services that are not covered benefits of this Plan 15 16

Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 10 copay for generic formulary drugs a 15 copay for formulary name brand drugs or a 30 copay for nonformulary
drugs per prescription unit or refill 18 19

Dental care Accidental injury benefit you pay nothing Preventive dental care and diagnostic services you pay nothing Restorative services periodontics oral surgery crowns and bridges dentures
preventive orthodontics and emergencies are covered you pay a fixed copay per procedure see copay schedule 20 21

Vision care One refraction annually You pay a 10 copay per visit 22
Out of pocket Copayments are required for a few benefits however after your out of pocket expenses reach a maximum of 2,000 per Self Only or 4,000 per Self and Family enrollment per calendar year
covered benefits will be provided at 100 This copay maximum does not include prescription drugs dental services eyeglasses or durable medical equipment 6

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2000 Rate Information for Altius Health Plans
Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to an FEBH Guide or contact the agency that maintains your health benefits enrollment
Postal rates apply to most career U S Postal Service employees but do not apply to non career Postal employees Postal retirees certain special Postal employment categories or associate members of any Postal employee organization If you are in a special Postal
employment category refer to the FEHB Guide for that category

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

Wasatch Front Self Only 9K1 78.83 38.14 170.80 82.64 93.06 23.91 93.26 23.71
Self and Family 9K2 175.97 81.36 381.27 176.28 207.74 49.59 201.02 56.31

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