Document Outline

• Summary of Benefits for Blue Shield of California Access+ 2000
• Non-Postal Premium

Pages 1--29 from michael.c

Enrollment Code
SJ1 Self Only
SJ2 Self and Family
Enrollment in this Plan is limited see pages 4 and 5 for requirements

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

Authorized for distribution by the United States
Office of
Personnel 1
1 Page 2 3
RI 73 574
Table of Contents Page

Introduction 3
Plain language 3
How to use this brochure 3
Section 1 Health Maintenance Organizations 4
Section 2 How we change for 2000 4
Section 3 How to get benefits 4 8
Section 4 What to do if we deny your claim or request for service 8 10
Section 5 Benefits 10 18
Section 6 General exclusions Things we don't cover 20

Section 7 Limitations Rules that affect your benefits 20 21
Section 8 FEHB facts 22 25
Department of Defense FEHB Demonstration Project 25 26
Inspector General Advisory Stop Healthcare Fraud 26
Summary of benefits 27
Premiums 28

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Blue Shield of California Access 2000
Introduction Blue Shield of California
50 Beale Street San Francisco CA 94105 1808

This brochure describes the benefits you can receive from Blue Shield of California Access under its contract CS2639 with the Office of Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law This
brochure is the official statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this brochure If you are enrolled for Self and Family coverage each eligible family member is also entitled to
these benefits
OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on page 4 Premiums are listed at the end of this brochure

Plain language
The President and Vice President are making 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 Access 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 benefit 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 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 HMOs 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 obtain 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 including an optional dental plan
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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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 copayments and coinsurance listed in this brochure When you receive emergency services you may have to submit claim forms If
you visit a Medical Eye Services provider for your annual eye refraction you will be asked to complete a brief claim form
You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change plans because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider will be available

and or remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of treatment

Section 2 How we change for 2000
Program wide To keep premiums as low as possible OPM has set a minimum copay of 10 for most primary changes care office visits
This year you have a right to more information about this Plan care management our networks facilities and providers

If you have a chronic or disabling condition and your provider leaves the Plan at our request you may continue to see your specialist for up to 90 days If your provider leaves the Plan and
you are in the second or third trimester of pregnancy you may be able to continue seeing your OB GYN until the end of your postpartum care You have similar rights if this Plan leaves the
FEHB program See Section 3 How to get benefits for more information
You may review and obtain copies of your medical records on request If you want copies of your medical records ask your health care provider for them You may ask that a physician

amend a record that is not accurate not relevant or incomplete If the physician does not amend your record you may attach a separate brief statement to it If they do not provide you with
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 Your share of the Blue Shield of California Access premium will increase by 11 2 for Self Plan Only or for Self and Family
The benefit for the diagnosis and treatment of infertility will not cover assisted reproductive technology ART procedures such as in vitro fertilization gamete and zygote intrafallopian
transfer and related services including medications laboratory and radiology services Artificial insemination is covered At the physician's office or pharmacy you pay 50 of allowable
charges for covered injectable drugs At Plan pharmacies you pay a 6 copay for covered oral infertility drugs

Prescription drug coverage will be provided with a 6 copay per prescription unit or refill for up to a 30 day supply Previously coverage was provided for a 34 day supply

Section 3 How to get benefits
What is this To enroll with us you must live or work in our service area This is where our providers practice Plan's service Our service area is
area

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County Name Excluded ZIP Codes Alameda None
Butte None Contra Costa None
County Name Excluded ZIP Codes
What is this El Dorado 95613 95619 95623 95633 95636 95643 95651 95656 95667 Plan's service 95672 95682 95684 95709 95720 95721 95726 95735 and 96150 to 96158

area Fresno None continued Kern 93501 93502 93504 93505 93516 93519 93527 93528 93554 to
93556 93560 and 93596 Kings None

Los Angeles 90704 Madera None
Marin None Merced None
Napa None Nevada 95724 95728 96111 and 96160 to 96162
Orange None Placer 95701 95714 95715 95717 96140 to 96143 96145 96146 and 96148
Riverside 92225 26 Sacramento None
San Bernardino 92242 92280 92304 92319 92338 and 92363 San Diego 91905 91906 91934 91948 91963 91980 91987 91990 to 91995
92004 and 92086 San Francisco None
San Joaquin None San Luis Obispo None
San Mateo None Santa Barbara None
Santa Clara None Santa Cruz None
Shasta None Solano None
Sonoma None Stanislaus None
Tulare None Ventura None
Yolo None
Ordinarily you must get your care from providers who contract with us If you receive care outside our service area we will normally pay only for emergency care We will not pay for any

other health care service except those that are specifically addressed in the sixth paragraph on page 12 and on page 19 under the heading Medical Care for Vacations Business Travel and
College Students
If you or a covered family member move outside the 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 like ours that has agreements with affiliates in other states See page 19 for details about our HMO Blue USA Away from
Home coverage 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

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How much do You must share the cost of some services This is called either a copayment a set dollar amount I pay for or coinsurance a set percentage of allowable charges Please remember you must pay this
services amount when you receive services except you pay nothing for preventive services like periodic physical exams well baby visits and maternity check ups See a complete list of these preventive services on pages 10 and 11

After you pay 1,000 in copayments or coinsurance for a Self Only enrollment or 2,000 for a Self and Family enrollment you do not have to make any further payments for most services for
the rest of the year This is called a catastrophic limit However copayments or coinsurance for 1 your prescription drugs 2 outpatient mental health and substance abuse services 3
infertility services or 4 the Access self referral specialty visit copayments do not count toward these limits and you must continue to make payments

How much do Be sure to keep accurate records of your copayments and coinsurance since you are responsible I pay for for informing us when you reach the limits
services continued

Do I have to You normally won't have to submit claims to us unless you receive emergency services from a submit provider who doesn't contract with us If you file a claim please send us all of the documents for
claims your claim as soon as possible You must submit claims by December 31 of the year after you received the services Either OPM or we can extend this deadline if you show that circumstances beyond your control prevented you from filing on time

Who provides Access is a mixed model Individual Practice Association IPA Medical Group HMO with an my health extensive network of providers conveniently located in the communities where you live and work
care Access offers a Health Plan with a choice of 280 Plan hospitals 160 other acute care hospitals 9,800 primary care physicians 17,000 specialists and other health care professionals Each family member has the freedom to choose a different physician You or your dependent s may
change primary care physicians by calling the Plan at 1 800 334 5847 or by submitting a Member Change Request Form to the Member Services Department The change will be effective on the
first day of the month after Blue Shield approves it Once your primary care physician change is effective all care must be provided or arranged by the new primary care physician except for 1
OB GYN services provided by an obstetrician gynecologist or family practice physician within the same IPA Medical Group as the primary care physician or 2 Access specialist self referral
visits
Changing your primary care physician during a course of treatment during hospitalization or while pregnant may interrupt the quality and continuity of your care For this reason the effective
date of your new primary care physician when requested in the three situations listed above will be the first of the month following discharge from the hospital delivery of the baby or the date it
is medically appropriate to transfer your care to your new primary care physician as determined by the Plan Exceptions must be approved by the regional Blue Shield Medical Director For
information about an exception to the above provisions please contact Member Services

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You will have the opportunity through our Personal Health Management Program sm to be an active participant in your own health care with Access by calling 1 800 244 4755 We'll help
you make a personal commitment to maintain and where possible improve your health status We believe that maintaining a healthy lifestyle and preventing illness are as important as caring
for your needs when you are ill or injured
Your Plan coverage includes worldwide emergency care Members may also receive care for urgent services when traveling out of state through HMO Blue USA Members call 1 800 4
HMO USA to obtain information about the nearest participating provider To arrange for urgent care while traveling out of the service area within California members call their primary care
physician or 1 800 334 5847
As a not for profit partner in your health care you'll receive the benefit of Blue Shield's 60 year commitment to service

The most important decision that you will make is your selection of a primary care physician It is through this physician that most all other health services are obtained Your primary care
physician is usually responsible for obtaining authorizations from the Plan before referring you to a specialist You can self refer to a participating physician in the same IPA Medical Group as
your primary care physician under the Access option and pay a 30 office copayment for this added freedom of choice with the exception of mental health care infertility urgent care and
allergy services Services of other providers are covered only when there has been a referral by your primary care physician with the exception of the Access self referral option and OB GYN
Services Access self referral and OB GYN visits must be to a physician in the same IPA MediWho

provides cal Group as your primary care physician to assure quality of care Your primary care physician my health will also make arrangements for hospitalizations
care continued
The Plan's provider directory lists primary care physicians family and general practitioners pediatricians internists and some OB GYNs with their locations and phone numbers and
whether or not the physician is accepting new patients Directories are updated on a regular basis but are subject to change without notice and are available at the time of enrollment or upon
request by calling the Member Services Department at 1 800 334 5847 you can find out if a physician participates with this Plan by calling this number If you are interested in receiving care
from a specific provider who is listed in the directory call the provider to verify that he or she still participates with the Plan and is accepting new patients Important note When you enroll in this
Plan services except for emergency benefits are provided through the Plan's delivery system the continued availability and or participation of any physician hospital or other
provider cannot be guaranteed
Should you decide to enroll you will be asked to complete a primary care physician selection form and send it directly to the Plan indicating the name s of the primary care physician s you

select for you and each member of your family
What to do if Call us We will help you select a new one my primary

care physician leaves the
Plan
What do I do if Talk to your Plan physician If you need to be hospitalized your primary care physician will make I need to go the necessary arrangements and supervise your care

into the hospital

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What to do if First call our customer service department at 1 800 334 5847 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
hospital when I are switching to us your former plan will pay for the hospital stay until join this Plan You are discharged not merely moved to an alternate care center or
The day your benefits from your former plan run out or The 92 nd 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 receive Your primary care physician will arrange your referral to a specialist The exceptions to this are specialty care 1 for true medical emergencies 2 when another physician is on call for your physician 3
when you self refer to an Access participating specialist not applicable to mental health care infertility urgent care and allergy services and 4 OB GYN services provided by an

obstetrician gynecologist or family practice physician within the same IPA Medical Group as your primary care physician In all other instances referral to a specialist is done at the primary care
physician's discretion if non Plan specialists or consultants are required the primary care physician will arrange appropriate referrals

The following procedures apply to all members except those using the Access self referral option When you receive a referral from your primary care physician you must return to the primary care
physician after consultation All follow up care must be provided or authorized by the primary care physician On referrals the primary care physician will give specific instructions to the specialist as
to what services are authorized If additional services or visits are suggested by the specialist you must first check with your primary care physician Do not go to the specialist unless your primary
care physician has arranged for an authorization for the referral in advance If you need to see a specialist frequently because of chronic complex or serious medical

How do I receive condition your primary care physician will develop a treatment plan that allow you to see your specialty care specialist for a certain number of visits without referrals Your primary care physician will use our criteria when creating your treatment plan

continued
What do I do if Your primary care physician will usually decide what specialty treatment you need However I am seeing a members can self refer to specialists in the same IPA Medical Group under the Access option
specialist when If you are not using the self referral option and your primary care physician decides to refer you I enroll to a specialist ask if you can see your current specialist If your current specialist does not
participate in your new IPA Medical Group you must receive treatment from a specialist who does Generally we will not pay for you to see a specialist who does not participate with our Plan

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

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

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

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

How do you Access covers drugs devices that are medically indicated and biological products no longer decide if a considered to be investigational by the Food and Drug Administration Coverage for other
service is procedures are reviewed by and decided by the Blue Shield of California Medical Policy experimental or Committee The primary criteria are that the proposed new procedures are safe and effective
investigational

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

We have 30 days from the date we receive your reconsideration request to 1 Maintain our denial in writing
2 Pay the claim 3 Arrange for a health care provider to give you the service or
4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30 days after we receive the additional information If we do not receive the requested information within 60 days we will make our

decision based on the information we already have
When may I ask You may ask OPM to review the denial after you ask us to reconsider our initial denial or OPM to review a refusal OPM will determine if we correctly applied the terms of our contract when we denied

denial your claim or request for service
What if I have a Call us at 1 800 334 5847 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 serious medical condition and deny your claim we will denied my request inform OPM so that they can give your claim expedited treatment too Alternatively you can
for care and my call OPM's health benefits Contract Division II at 202 606 3818 between 8 a m and 5 p m condition is serious Serious or life threatening conditions are ones that may cause permanent loss of bodily functions or death if they are not treated as soon as possible
or life threatening

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Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold time limits our initial denial or refusal of service You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your request within 120 days of the date you asked us to reconsider your claim

2 You provided us with additional information we asked for and we do 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 Your request must be complete or OPM will return it to you You must send the following OPM information
1 A statement about why you believe our decision is wrong based on specific benefit provisions in this brochure

2 Copies of documents that support your claim such as physicians letters operative reports bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim 4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to which claim

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

What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our upholds the Plan's decision your only recourse is to sue
denial If you decide to sue you must file 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 lawsuits benefits and payment of benefits The Federal court will I file a lawsuit base its review on the record that was before OPM when OPM made its decision on your claim
You may recover only the amount of benefits in dispute

You or a person acting on your behalf may not sue to recover benefits on a claim for treatment services supplies or drugs covered by us until you have completed the OPM review
procedure described above

Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects from The Privacy Act you and us to determine if our denial of your claim is correct The information OPM collects during the review process becomes a permanent part of your disputed claims file and is subject
to the provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this information to support the disputed claim decision If you file a lawsuit this information
will become part of the court record

Section 5 Benefits
Medical and Surgical Benefits

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What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan physicians and other Plan providers This includes all necessary office visits you pay a 10 office visit copay for other than preventive and maternity services but no additional copay for
laboratory tests and X rays Within the Service Area house calls will be provided if in the judgment of the Plan physicians such care is necessary and appropriate you pay a 25 copay
for a Plan physician's house call 5 for home visits by nurses and health aides
The following services are included
Preventive care including well baby care and periodic check ups You pay nothing
Mammograms are covered as follows for women 35 through 39 one mammogram during these five years for women 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 Plan physician as medically necessary to diagnose or treat your illness You pay nothing

Routine immunizations and boosters You pay nothing
Hearing screening by the primary care physician for members under the age of 18 to determine the need for an audiogram or hearing correction You pay nothing

Vision screening by the primary care physician for members under the age of 18 to determine the need for refraction or vision correction You pay nothing
Consultations by specialists You pay 10
Self referral to a participating specialist through the Access option You pay 30 per visit

Diagnostic procedures such as laboratory tests and X rays You pay nothing
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
Medical and Surgical Benefits continued

What is covered Complete obstetrical maternity care for all covered females including prenatal delivery continued and postnatal care by a Plan physician 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 the hospital stay is less than 48 hours after a

regular delivery or 96 hours after a cesarean section delivery a follow up visit for the mother and newborn within 48 hours of discharge is covered when prescribed by the treating
physician The treating physician in consultation with the mother will determine whether this visit will occur at home the contracted facility or the physician's office Also included is
the prenatal diagnosis of genetic disorders of the fetus in high risk pregnancy cases 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 You pay nothing
Voluntary sterilization and family planning services You pay 100 for tubal ligation 75 for vasectomy nothing for office visits

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Diagnosis and treatment of diseases of the eye You pay 10
Allergy testing and treatment You pay 10 per visit You pay nothing for injectables serum unless they are made separately e g customized antigens in which case
you pay a coinsurance of 50 of allowable charges
The insertion of internal prosthetic devices such as pacemakers and artificial joints You pay 10

Cornea kidney heart skin lung heart and lung in combination kidney and pancreas in combination liver transplants allogeneic donor bone marrow transplants autologous
bone marrow transplants autologous stem cell and peripheral stem cell support for the following conditions when authorized in writing by the Blue Shield Medical Director and
performed at approved facilities acute lymphocytic or non lymphocytic leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma advanced
neuroblastoma and testicular mediastinal retroperitoneal and ovarian germ cell tumors Breast cancer multiple myeloma and epithelial ovarian cancer are covered only when
approved by the Plan's Medical Director and performed as part of a clinical trial conducted at a Cancer Research Facility that is funded by the National Cancer Institute You pay
nothing Related medical and hospital expenses of the donor are covered when the recipient is covered by this Plan

Women who undergo mastectomies may at their option remain in the hospital up to 48 hours after the procedure You pay nothing Coverage includes all stages of
reconstruction of the breast on which the mastectomy was performed and surgery and reconstruction of the other breast to produce a symmetrical appearance Treatment of
physical complications of mastectomy including lymphedemas is also a covered benefit
Outpatient hospital services for treatment or surgery and necessary supplies You pay 50 per treatment or surgery

Chemotherapy radiation therapy dialysis and inhalation therapy You pay 10 per office visit or you pay nothing in a hospital setting
Surgical treatment of morbid obesity You pay nothing as an inpatient
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
Medical and Surgical Benefits continued

What is covered Orthopedic devices and their repair such as braces functional foot orthoses You pay continued 50 of allowable charges

Prosthetic services and their repair such as artificial limbs and contact lenses necessary to treat certain medical eye conditions Contact the plan for details Breast
prostheses including the surgical bra used for an external prosthesis and necessary replacement prostheses and bras are covered benefits You pay 50 of allowable
charges
Durable medical equipment such as wheelchairs and hospital beds You pay 50 of allowable charges

Home health service of nurses and health aides including intravenous fluids and medications when prescribed by a Plan physician who will periodically review the
program for continuing appropriateness and need You pay 5 per visit
All necessary medical or surgical care in a hospital or extended care facility from Plan physicians and other Plan providers You pay nothing

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Urgent care services through HMO Blue USA when traveling out of state by calling 1800 4 HMO USA for a referral When traveling within State but out of your Service Area
call your primary care physician or 1 800 334 5847 You pay a 50 per visit copay
Injectable medications Other than allergy and infertility injections you pay nothing

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 Medically necessary non surgical treatment e g splint therapy and physical therapy of Temporomandibular Joint Syndrome
TMJ is covered Surgical and arthroscopic treatment of TMJ is covered if prior history shows conservative medical treatment has failed You pay nothing as an inpatient All other
procedures involving the teeth or intra oral areas surrounding the teeth are not covered including any dental care involved in treatment of temporomandibular joint TMJ pain
dysfunction syndrome
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 You pay nothing as an inpatient

Cryosurgery for localized prostate cancer is considered to be an appropriate treatment and is a covered benefit when medically necessary You pay 50 per treatment or surgery for outpatient
hospital services or nothing in the hospital This surgical procedure is still considered to be experimental and investigational for salvage therapy and is not covered for local failures after
radical prostatectomy external beam irradiation and brachytherapy
Rehabilitative therapy is covered for physical speech occupational and inhalation you pay a 10 copay per outpatient session This is a covered benefit when determined by the Plan to be
medically necessary and it is demonstrated that the member's condition will significantly improve as a result of these services Speech therapy is limited to treatment of certain speech
impairments of organic origin Occupational therapy is limited to services that assist the member to achieve and maintain self care and improved functioning in other activities of daily living

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS

Medical and Surgical Benefits continued
Limited benefits Chiropractic services are covered up to 20 visits per calendar year You pay a 10 copay per continued visit Each member is allowed a pre authorized appliance benefit of up to 50 per year Examples of covered appliances are elbow supports back supports thoracic and cervical

collars Unlimited chiropractic discounts are also available See mylifepath features on page 19
Diagnosis and treatment of infertility is covered Artificial insemination is covered you pay 50 of allowable charges for all services Cost of donor sperm eggs and frozen embryos and

their collection and storage is not covered Other assisted reproductive technology ART procedures that enable a woman with otherwise untreatable infertility to become pregnant
through other artificial conception procedures such as in vitro fertilization and embryo transfer are not covered At the physician's office or pharmacy you pay 50 of allowable charges for
covered injectable drugs At Plan pharmacies you pay a 6 copay for covered oral infertility drugs

Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is provided at a Plan facility if medically necessary with the appropriate treatment plan you
pay 10 per visit

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What is not covered Physical examinations not necessary for medical reasons such as those required for obtaining or continuing employment or insurance attending school or camp or travel
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Homemaker services
Hearing aids and examination for hearing aids exams only covered for children under 18
Transplants not listed as covered
Assisted reproductive technology ART procedures

Organ donor costs and travel expenses
Routine foot care
Wigs
Speech language or vision assistance devices
Services for or related to acupuncture see page 19 for unlimited acupuncture discounts
Surgery to correct refractive error such as radial keratotomy and refractive keratoplasty

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 physician You pay nothing All necessary services are covered including

Semiprivate room accommodations when a Plan physician determines it is medically necessary the physician may prescribe private accommodations or private duty nursing
care
Specialized care units such as intensive care or cardiac care units
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
Hospital Extended Care Benefits continued

What is covered continued
Extended care The Plan provides a comprehensive range of benefits up to 100 days each calendar year when full time skilled nursing care is necessary and confinement in a skilled nursing facility is
medically appropriate as determined by a Plan physician and approved by the Plan Admissions to a subacute care setting require prior Plan approval and are limited to 100 days each calendar

year 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 physician

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Hospice care Supportive and palliative care for a terminally ill member is covered in the home or a hospice facility Care received in the home is limited to 100 visits per year and is subject to a 10 copay
for physicians and a 5 copay per visit for other health care providers Care received in a hospice facility provides for 100 days of service applied against the Extended Day Care Limits without

copayment Services include inpatient and outpatient care and family counseling these services are provided under the direction of a Plan physician 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 physician

Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan physician determines there procedures is a need for hospitalization for reasons totally unrelated to the dental procedure the Plan will
cover the hospitalization but not the cost of 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 physician determines that outpatient management is not medically appropriate See pages 16 and 17 for more about substance abuse benefits

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

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
Emergency Benefits
What is a A medical emergency is the sudden and unexpected onset of a condition or an injury that you medical believe endangers your life or could result in serious injury and disability and requires

emergency immediate medical or surgical care Some problems are emergencies because if not treated promptly they might become more serious examples include deep cuts and broken bones Others are emergencies because they are potentially life threatening such as heart attacks
strokes poisonings gunshot wounds or sudden inability to breathe There are many other acute conditions that you and the Plan may determine are medical emergencies what they all have in
common is the need for quick action

Emergency Benefits continued
Emergencies If you are in an emergency situation please call your primary care physician In extreme within the emergencies if you are unable to contact your physician contact the local emergency system
service area e g the 911 telephone system or go to the nearest hospital emergency room Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan You or a family member should notify the Plan within 48 hours It is your responsibility to ensure that the
Plan has been timely notified
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to notify the Plan within
that time If you are hospitalized in non Plan facilities and a Plan physician believes care can

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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
Any follow up care recommended by non Plan providers must be approved by the Plan or provided by Plan providers

Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 50 per hospital emergency room visit or urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital the copay is
waived

Emergencies outside Benefits are available for any medically necessary health service that is immediately required the service area because of injury or unforeseen illness

If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to notify the Plan within that
time If a Plan physician believes care can be better provided in a Plan hospital you will be transferred when medically feasible with any ambulance charges covered in full

Plan pays Reasonable charges for emergency care services to the extent the services would have been covered if received from Plan providers
You pay 50 per emergency room visit or 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 copay is
waived

What is covered Emergency care at a physician's office or an urgent care center
Emergency care as an outpatient or inpatient at a hospital including physician's services

Ambulance service approved by the Plan

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

Emergency Benefits continued
Filing claims With your authorization the Plan will pay benefits directly to the providers of your emergency for non Plan care upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim
providers 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 Mail this information to Blue Shield of California HMO Member Services P O Box
272550 Chico CA 95927 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 pages 8 and 9

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Mental Conditions Substance Abuse Benefits
Mental conditions What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis
and treatment of acute psychiatric conditions including treatment of mental illness or disorders
Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Outpatient Up to 40 outpatient visits to Plan physicians consultants or other psychiatric personnel each care calendar year you pay a 25 copay for each covered visit 1 20 and 50 of allowable charges for
visits 21 40 all charges thereafter

Inpatient Up to 30 days of hospitalization each calendar year you pay 50 per day for first 30 days or 25 care per day of day care for up to 60 days or a combination of inpatient and day care where 2 daycare
days count as 1 inpatient day up to a maximum of 30 equivalent inpatient days You pay all charges thereafter

Psychiatric day care is care in which patients participate during the day returning to their homes or other community placement during the evening or night
What is not Care for psychiatric conditions that in the professional judgment of Plan physicians are not covered subject to significant improvement through relatively short term treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless determined by a Plan physician to be necessary and appropriate
Psychological testing that is not medically necessary to determine the appropriate treatment of a short term psychiatric condition
Self referrals to psychiatrists or other mental health care providers under the Access selfreferral option
Substance abuse This Plan provides medical and hospital services such as acute detoxification services for the What is covered medical non psychiatric aspects of substance abuse including alcoholism and drug addiction the
same as for any other illness or condition Services for the psychiatric aspects are provided in conjunction with the mental conditions benefit shown above Outpatient visits to Plan providers

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
Mental Conditions Substance Abuse Benefits continued

Substance abuse for treatment are covered as well as inpatient services necessary for diagnosis and treatment The What is covered mental conditions benefits visit limitation and copays apply to any covered substance abuse care
continued What is not Treatment that is not authorized by a Plan physician
covered Self referrals to any mental health provider through the Access self referral option

Prescription Drug Benefits
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What is covered Prescription drugs prescribed by a Plan or referral physician and obtained at a Plan pharmacy will be dispensed for up to a 30 day supply Coverage is based on the use of the Prescription Drug Formulary a copy of which is available to members Non formulary drugs will be covered
when prescribed by a physician and approved by the Plan Members physicians are responsible for obtaining authorizations from the Plan for all non formulary drugs Members should not
become directly involved with the Plan for this preauthorization process Instead their physicians should document medical necessity for non formulary drugs during regular business hours by
calling the Plan's toll free Pharmacy Services Prior Authorization hotline 1 800 535 9481 If all necessary documentation is available from your physician prior authorization approval or denial
will be provided to your physician within two working days of the request
Medications are selected for inclusion in Blue Shield's Outpatient Prescription Drug Formulary based on safety efficacy and FDA bioequivalency data The Blue Shield Pharmacy and
Therapeutics Committee reviews new drugs and clinical data four times a year
Members may call Blue Shield Member Services at 1 800 334 5847 to find out if a specific drug is included in the Formulary New members receive a printed copy of the Formulary with their
welcome kits Formulary information is also available on Blue Shield's web site at http www blueshieldca com

In lieu of brand name drugs generic drugs will be dispensed when substitution is permissible by the physician If you request a brand name drug when a generic drug is available you pay the
difference between the cost of the brand name drug and its equivalent generic drug plus the copayment You pay a 6 copay per prescription at Plan pharmacies To obtain prescription
drugs present your Access identification card at a participating pharmacy For out of state emergencies you pay a 6 copay

Mail Order Drug Program Prescriptions are also available by mail for up to a 90 day supply Generic drugs will be dispensed in lieu of name brand drugs when substitution is permissible by
the physician You pay a 6 copay per prescription unit or refill If you request a brand name drug when a generic drug is available you pay the difference between the cost of the brand name
drug and its equivalent generic drug plus the copayment Call Member Services at 1 800 334 5847 to receive a packet for ordering prescriptions through the mail
Covered medications include
Medically necessary drugs for which a prescription is required by law
Oral contraceptive drugs up to a three cycle supply may be obtained for a single copay charge

Diaphragms when obtained at a Plan pharmacy
Insulin with a copay for each 30 or 90 day supply
Disposable needles and syringes needed for injecting covered medication
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
Prescription Drug Benefits continued

What is covered Diabetic supplies limited to insulin syringes needles and glucose testing tablets and strips continued Intravenous fluids and medications for home use and some injectable drugs such as Depo
Provera are covered under Medical and Surgical Benefits Diaphragms are covered if your physician writes a prescription for the device

Drugs for sexual dysfunction or sexual inadequacies will be covered when the dysfunction is caused by medically documented organic disease Prior Plan approval is required and the
maximum dosage dispensed will be limited by the protocols established by the Plan Certain drugs for these conditions are not available through the Mail Order option

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What is not Drugs available without a prescription or for which there is a nonprescription equivalent covered available
Drugs obtained at a non Plan pharmacy except for out of area emergencies
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
IUDs and Norplant dispensed by your physician are covered under Medical and Surgical Benefits and not the Prescription Drug Benefit

Implanted time release medications
Drugs for weight loss
Smoking cessation drugs

Other Benefits
Dental care Accidental injury Restorative services and supplies necessary to promptly repair but not replace sound natural
benefit teeth are covered The need for these services must result from an accidental injury commencing within 90 days of the accidental injury or within 90 days of medical appropriateness of treatment
and within one year of the injury You pay a 10 copay per visit
See page 19 for details about a comprehensive low cost optional Blue Shield dental plan
Vision care

What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of disease of the eye annual eye refractions to provide a written lens prescription may be obtained from
Medical Eye Services MES providers you pay a 10 copayment MES directories can be ordered by calling 1 800 334 5847

What is not Corrective lenses or frames covered Eye exercises

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN PHYSICIANS
Non FEHB Benefits Available to Plan Members The benefits described on this page are neither offered nor guaranteed under the contract with FEHB but are made available to all

enrollees and family members who are members of this Plan The cost of the benefits described on this page is not included in the FEHB premium and any charges for these services do not count toward any FEHB deductibles or out of pocket maximums These
benefits are not subject to the FEHB disputed claims procedure
Blue Shield Dental Option Comprehensive and Affordable CAUTION When shopping for a dental plan please carefully compare 1 copayments 2 waiting periods and 3 dues

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19 Page 20 21
Enroll in Access and pay dues directly to Blue Shield to join this no waiting period dental plan Dues can be paid monthly or quarterly Dues are also shown on a biweekly basis for your convenience in comparing costs Call 1 888 271 4929 for a list of
dentists a summary of benefits and an enrollment form
Biweekly Dues Monthly Dues Quarterly Dues Self only 6.95 15.05 45.15

Two party 13.64 29.56 88.68 Family 20.08 43.51 130.53

Care must be received from or arranged by a Blue Shield Dental Option provider Below are sample copayments
Office visits 5 Fillings per surface 15 Root canal one canal 125 Bitewing X rays 0 Metal crowns each 250 Full upper or lower denture 250

Prophylaxis 0 Single routine extraction 20 Orthodontics children only 1,800
Receive Discounts from Vision One Eyecare Program on Frames and Lenses Federal employees with Access coverage can enjoy savings of up to 66 7 on frames and lenses through our Vision One Eyecare

Program at almost 250 Cole Vision California locations Cole Vision services are available in the optical departments of many Sears Montgomery Ward and JCPenney stores at Pearle Vision locations and at offices of participating private practice doctors There is no
added premium for this money saving feature Simply present your Access identification card when you pay for your eyewear and the discounts are automatic

For coverage of eye refractions see page 18
Significant Discounts through the mylifepath sm Program Acupuncture Massage More Access offers you participation in mylifepath which entitles you to significant discounts on health and wellness services When you

see a practitioner in the mylifepath network you'll experience substantial savings on acupuncture chiropractic massage fitness centers health spas and wellness programs You will be responsible for all charges remaining after the discounts For more details on
all features please call 1 888 999 9452 Also visit our website mylifepath com for health information and news about other valueadded features

Medical Care for Vacations Business Travel and College Students HMO Blue USA covers you and eligible family members in hundreds of cities in 43 states and the District of Columbia while you're
on vacation on business travel or away from home at college There are no additional premiums for this Away from Home Care You pay office copayments which vary from state to state 5 to 25 for guest visits and 50 for urgent care visits Call 1 800 334 5847
for details
Blue Shield 65 Plus A Medicare Choice Prepaid Plan

This Plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare As indicated on page 20 annuitants and former spouses with FEHB coverage and Medicare Part B may elect to drop their FEHB coverage and enroll in a Medicare prepaid
plan if one is available in their area They may then later reenroll in the FEHB Program Most Federal annuitants have Medicare Part A Those without Medicare Part A may join this Medicare prepaid plan but will have to pay for hospital coverage in certain instances
in addition to the Part B premium Before you join the plan ask whether the plan covers hospital benefits and if so what you will have to pay Contact your retirement system for information on dropping your FEHB enrollment and changing to a Medicare prepaid
plan Contact us at 1 888 713 0000 for information on the Medicare prepaid plan and the cost of that enrollment Blue Shield 65 Plus is now available in Alameda Contra Costa Kern Los Angeles Orange Riverside Sacramento San Bernardino San Diego San
Francisco San Mateo Santa Clara and Ventura counties
Benefits on this page are not part of the FEHB Contract

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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 physician determines it is medically necessary to prevent diagnose or treat your illness or condition
We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice

Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest

Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program
Expenses you incurred while you were not enrolled in this Plan
Procedures services drugs and supplies related to sexual dysfunction or sexual inadequacies including penile prostheses except as provided for medically documented treatment of organically based conditions

Services performed by a close relative the spouse child brother sister or parent of a subscriber or dependent or a person who ordinarily resides in the member's home and

Hospitalization or confinement in a health facility for treatment of eating disorders such as bulimia anorexia etc except to treat separately identified psychiatric or medical conditions arising from such disorders when an acute level of care is
medically necessary

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

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

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

If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration SSA office or request it from SSA at 1 800 638 6833 For information on the Medicare Choice
plan offered by Access see the bottom of page 19

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

When others When you receive money to compensate you for medical or hospital care for injuries or illness are responsible that another person caused you must reimburse us for whatever services we paid We will cover
for injuries 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 at 530 666 2238 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 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 determines 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 for which a local State or Federal Government agency government directly or indirectly pays
agencies

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Section 8 FEHB Facts
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the information about right to information about your health plan its networks providers and facilities You can also
your HMO find out about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's website at www opm gov lists the specific types of information that we must make
available to you
If you want specific information about us call 1 800 334 5847 or write to Members Services Department Blue Shield of California Access P O Box 272550 Chico CA 95927 You may
also contact us by fax at 916 351 7790 or visit our website at www blueshieldca 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 Benefit Plans brochures for other plans and other materials you need to make
enrolling in the an informed decisions about FEHB Program When you can change your enrollment
How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter military service or retire

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

When are my The benefits in this brochure are effective on January 1 If you are new to this plan your benefits and coverage and premiums begin on the first day of your first pay period that starts on or after
premiums effective January 1 Annuitant's premiums begin January 1
What happens When you retire you can usually stay in the FEHB Program Generally you must have been when I retire enrolled in the FEHB Program for the last five years of your Federal service If you do not meet
this requirement you may be eligible for other forms of coverage such as Temporary Continuation of Coverage which is described later in this section

What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and your coverage are unmarried dependent children under age 22 including any foster or step children for which your
available for me employing or retirement office authorizes coverage Under certain circumstances you may also and my family get coverage for a disabled child 22 years of age and 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

23 23
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Are my medical and We will keep your medical and claims information confidential Only the following will have claims record access to it
confidential OPM this plan and subcontractors when they administer this contract Law enforcement officials when investigating and or prosecuting alleged civil or criminal
activities OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that do not disclose your identity or
OPM when reviewing a disputed claim or defending litigation about a claim

Information for new members
Identification We will send you an Identification ID card Use your copy of the Health Benefits Election cards Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You
can also use an Employee Express confirmation letter
What if I paid a Your old plan's deductible continues until our coverage begins deductible under

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

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

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

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

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

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What is TCC Key points about TCC continued
You can pick a new plan If you leave Federal service you can receive TCC for up to 18 months after you separate

If you no longer qualify as a family member you can receive TCC for up to 36 months Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32 nd day after your regular coverage ends even if several months have
passed You pay the total premium and generally a 2 percent administrative charge The
government does not share your costs You receive another 31 day extension of coverage when your TCC enrollment ends unless
you cancel your TCC or stop paying the premium You are not eligible for TCC if you can receive regular FEHB Program benefits

How do I enroll If you leave Federal service your employing office will notify you of your right to enroll under in TCC TCC You must enroll within 60 days of leaving or receiving this notice whichever is later
Children You must notify your employing or retirement office within 60 days after your child is no longer an eligible family member That office will send you information about
enrolling in TCC You must enroll your child within 60 days after they become eligible for TCC or receive this notice whichever is later

Former spouses You or your former spouse must notify your employing or retirement office within 60 days of one of these qualifying events
Divorce Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about enrolling in TCC Your former spouse must enroll within 60 days after the event which
qualifies him or her 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 You may convert to an individual policy if convert to
individual Your coverage under TCC or the spouse equity law ends If you cancelled your coverage 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 your receive this notice
However if you are a family member who is losing coverage the employing or retirement office will not notify you You must apply in writing to us within 31 days after you are no longer
eligible for coverage
Your benefits and rates will differ from those under the FEHB Program however you will not have to answer questions about your health and we will not impose a waiting period or limit
your coverage due to pre existing conditions

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How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Certificate of Coverage that indicates how long you were enrolled with us You can use this certificate
Group Health when getting health insurance or other health care coverage You must arrange for the other Plan Coverage 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

Department of Defense FEHB Demonstration Project What is the Department of Defense DoD and FEHB Program Demonstration Project
The National Defense Authorization Act for 1999 Public Law 105 261 established the DoD FEHBP Demonstration Project It allows some active and retired uniformed service members and their dependents to enroll in the FEHB Program The demonstration
will last for three years beginning with the 1999 Open Season for the year 2000 Open Season enrollments will be effective January 1 2000 DoD and OPM have set up some special procedures to successfully implement the Demonstration Project noted below
Otherwise the provisions described in this brochure apply
Who is Eligible
DoD determines who is eligible to enroll in FEHB Generally you may enroll if
You are an active or retired uniformed service member and are eligible for Medicare
You are a dependent of an active or retired uniformed service member and are eligible for Medicare
You are a qualified former spouse of an active or retired uniformed service member and you have not remarried or
You are a survivor dependent of a deceased active or retired uniformed service member and
You live in one of the eight geographic demonstration areas
If you are eligible to enroll in a plan under the regular Federal Employees Health Benefits Program you are not eligible to enroll under the DoD FEHBP Demonstration Project

Where are the demonstration areas
Dover AFB DE
Commonwealth of Puerto Rico
Fort Knox KY
Greensboro Winston Salem High Point NC
Dallas TX
Humboldt County CA area
Naval Hospital Camp Pendleton CA
New Orleans LA

When Can I Join
Your first opportunity to enroll will be during the 1999 Open Season November 8 1999 through December 13 1999 Your coverage will begin January 1 2000 DoD has set up an Information Processing Center IPC in Iowa to provide you with information about

how to enroll IPC staff will verify your eligibility and provide you with FEHB Program information plan brochures enrollment instructions and forms The toll free phone number for the IPC is 1 877 DOD FEHB 1 877 363 3342

You may elect coverage for yourself self only or for you and your family self and family during the 1999 2000 and 2001 Open Seasons Your coverage will begin January 1 of the year following the Open Season that you enrolled
If you become eligible for the DoD FEHBP Demonstration outside of Open Season contact the IPC to find out how to enroll and when your coverage will begin

26 26
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DoD has a web site devoted to the Demonstration Project You can view information such as their Marketing Beneficiary Education Plan Frequently Asked Questions demonstration area locations and zip code lists at www tricare osd mil fehbp You can also view
information about the demonstration project including The 2000 Guide to Federal Employees Health Benefits Plans Participating in the DoD FEHBP Demonstration Project on the OPM web site at www opm gov

Am I eligible for Temporary Continuation of Coverage TCC
See Section 10 FEHB Facts for information about TCC Under this Demonstration Project the only individual eligible for TCC is one who ceases to be eligible as a member of family under your self and family enrollment This occurs when a child turns 22 for

example or if you divorce and your spouse does not qualify to enroll as an unremmaried former spouse under title 10 United States Code For these individuals TCC begins the day after their enrollment in the DoD FEHBP Demonstration Project ends TCC
enrollment terminates after 36 months or the end of the Demonstration Project whichever occurs first You your child or another person must notify the IPC when a family member loses eligibility for coverage under the DoD FEHBP Demonstration Project

TCC is not available if you move out of a DoD FEHBP Demonstration Project area you cancel your coverage or your coverage is terminated for any reason TCC is not available when the demonstration project ends

Do I have the 31 day Extension and Right to Convert
These provisions do not apply to the DoD FEHBP Demonstration Project

Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for
services you did not receive billed you twice for the same service or misrepresented any information do the following

Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 1 800 334 5847 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

Summary of Benefits for Blue Shield of California Access 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
27 27
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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 PHYSICIANS
Benefits Plan pays provides Page

Inpatient Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes care in hospital physician care room and board general nursing care private room and private
nursing care if medically necessary diagnostic tests drugs and medical supplies use of operating room intensive care and complete maternity care You pay nothing 13

Extended care All necessary services limited to 100 days each calendar year You pay nothing 14
Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care or conditions 60 days of day care or a combination as described per year You pay 50 per inpatient day
and 25 per day care day 16
Substance Covered under Mental Conditions 16 abuse

Outpatient Comprehensive range of services such as diagnosis and treatment of illness or injury care including specialist's care You pay a 10 copay per office visit 30 per self referred
Access specialist office visit 25 per house call by physician Preventive care including well baby care periodic check ups and routine immunizations laboratory tests and X rays
complete maternity care You pay nothing 10
Home health All necessary visits by nurses therapists and health aides You pay 5 per visit 10 care

Mental Up to 40 outpatient visits per year You pay a 25 copay per visit for visits 1 20 50 of conditions charges for visits 21 40 16
Substance Covered under Mental Conditions 16 abuse
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 50 copay to the hospital for each emergency room visit and any charges for services
that are not covered benefits of this Plan 14

Prescription drugs Drugs prescribed by a Plan physician and obtained at a Plan pharmacy or through the Plan's mail order program You pay a 6 copay per prescription unit or refill 17

Dental care Accidental injury benefit you pay 10 per office visit 18 Optional comprehensive dental plan you pay total premium plus various copays 19
Vision care One eye refraction annually You pay a 10 copay 18
Out of pocket maximum Copayments and percentages of allowable charges are required for a few benefits however after your out of pocket expenses reach a maximum of 1,000 per Self Only or 2,000 per
Self and Family enrollment per calendar year covered benefits will be provided at 100 This copay maximum does not include charges for prescription drugs outpatient mental

health and substance abuse infertility services or the 30 copay for self referral specialty visits 5

2000 Rate Information for Blue Shield of California Access
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Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the FEHB Guide for that category or contact the agency that maintains your health benefits enrollment
Postal rates apply to most career U S Postal Service Employees In 2000 two categories of contribution rates referred to as Category A and Category B rates will apply for certain career employees If you are a career postal employee but
not a member of a special postal employment class refer to the category definitions in The Guide to Federal Employees Health Benefits Plans for United States Postal Service Employees RI 70 2 to determine which rate applies to you

Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes or associate members of any postal employee organization Such persons not subject to postal rates must refer to the applicable Guide to
Federal Employees Health Benefits Plans

Postal Premium A Postal Premium B Non Postal Premium
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

Self Only SJ1 61.47 20.49 133.19 44.39 72.74 9.22 72.74 9.22
Self and Family SJ2 152.50 50.83 330.41 110.14 180.46 22.87 180.46 22.87

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