Serving Central and Eastern Kentucky
Enrollment in this plan is limited see page 5 for requirements For changes in benefits
see page 4
Enrollment code
XW1 Self Only
XW2 Self and family
This service area has a Commendable
Accreditation from the NCQA See the
2000 Guide for more information on NCQA
Visit the OPM website at http www opm gov insure
and
our website at http www advantagecare com
Authorized for distribution by the
United States
Office of
Personnel
Management RI73 645
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Advantage Care Inc 2000
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 4
Section 3 How to get benefits 5 7
Section 4 What to do if we deny your claim or request for service 7 8
Section 5 Benefits 9 16
Medical and Surgical Benefits Hospital Extended Care Benefits Emergency
Benefits Mental Conditions Substance Abuse Benefits Prescription Drug
Benefits
Section 6 General exclusions Things we don't cover 17
Section 7 Limitations Rules that affect your benefits 17 18
Section 8 FEHB facts 19 22
Inspector General Advisory Stop Healthcare Fraud 23
Summary of benefits Inside back cover
Premiums Back cover
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Advantage Care Inc 2000
Introduction
Advantage Care Inc
120 Prosperous Place Suite 300
Lexington KY 40509
This brochure describes the benefits you can receive from Advantage Care under its contract CS 2709 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 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 Advantage Care Inc as this Plan throughout this brochure even though in other legal documents you will see a plan referred
to as a carrier
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 2
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Advantage Care Inc 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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Advantage Care Inc 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and other
providers that contract with us These providers coordinate your health care services The care you receive includes preventative care
such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury
When you receive services from our providers you will not have to submit claim forms or pay bills However when you receive services
you must pay copayments and coinsurance listed in this brochure
When you receive emergency services you may have to submit claim forms
You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change plans
because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider will be available and or
remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of treatment
Section 2 How We Change For 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary care office
changes 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
You may review and obtain copies of your medical records on request You may ask that a physician amend
a record that is not accurate relevant or complete If the physician does not amend your record you may add
a brief statement to the record
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 non postal premium will decrease by 20.0 for Self Only or 33.8 for Self and Family
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 4
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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 Our service area
Plan's service is Adair Anderson Bath Bell Bourbon Boyle Bracken Breathitt Casey Clark Clay Clinton Estill Fayette
area Fleming Franklin Garrard Grant Harrison Jackson Jessamine Knott Knox Laurel Lee Leslie Lewis Lincoln Madison Magoffin Marion Mason McCreary Menifee Mercer Montgomery Nicholas Owen Owsley Perry
Powell Pulaski Robertson Rockcastle Russell Scott Washington Wayne Whitley Wolfe and Woodford counties
in the state of Kentucky
Ordinarily you must get your care from providers who contract with us If you receive care outside our service area
we will pay only for emergency care We will not pay for any other health care services
If you or a covered family member move outside of our service area you can enroll in another plan If your
dependents live out of the area for example if your child goes to college in another state you should consider
enrolling in a fee for service plan or an HMO that has agreements with affiliates in other areas 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 a
pay for services set percent of charges Please remember you must pay this amount when you receive services
After you pay 1,000 in copayments or coinsurance for one family member or 2,000 for two or more family
members you do not have to make any further payments for certain services for the rest of the year This is called a
catastrophic limit However copayments or coinsurance for infertility services do not count toward these limits and
you must continue to make these payments
Be sure to keep accurate records of your copayments and coinsurance since you are responsible for informing us
when you reach the limits
Do I have to You normally won't have to submit claims to us unless you receive emergency services from a provider who doesn't
submit claims contract with us If you file a claim please send us all of the documents for your claim as soon as possible You must submit claims by December 31 of the year after the year you received the service Either OPM or we can
extend this deadline if you show that circumstances beyond your control prevented you from filing on time
Who provides Advantage Care Inc is a mixed model HMO The physician providers for Advantage Care Inc include primary
my health care and specialty care physicians from the communities which Advantage Care Inc serves There are 600 primary care doctors over 700 specialists 44 hospitals and over 700 pharmacies available to care for Advantage Care Inc
members Members will find that most of the participating primary care doctors are accepting new patients A
complete listing of providers is available in the Directory of Providers
What do I do if Call us We will help you select a new one
my primary care
physician leaves
the Plan
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Section 3 How To Get Benefits continued
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 the
need to go into necessary hospital arrangements and supervise your care
the hospital
What do I do if First call our membership services department at 800 850 8585 If you are new to the FEHB Program we will
I'm in the arrange for you to receive care If you are currently in the FEHB Program and are switching to us your former plan
hospital when I 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 participating specialist
specialty care If you need to see a specialist frequently because of a chronic complex or serious medical condition your primary
care physician will discuss a treatment plan with the Advantage Care health services staff 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 and obtain a referral from the plan prior to your first visit to the specialist
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 ask if
am seeing a you can see your current specialist If your current specialist does not participate with us you must receive treatment
specialist when from a specialist who does Generally we will not pay for you to see a specialist who does not participate with our
I enroll Plan
What do I do if Call your primary care physician who will arrange for you to see another specialist You may receive services from
my specialist your current specialist until we can make arrangements for you to see someone else However you should obtain a
leaves the Plan referral for all specialty services from the Health Services Department prior to a visit
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 Again you should obtain a referral to this provider from the Health
the Plan or this Services Department
Plan leaves the You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and you enroll in
Program a new FEHB plan Contact the new plan and explain that you have a serious or chronic condition or are in your
second or third trimester Your new plan will pay for or provide your care for up to 90 days after you receive notice
that your prior plan is leaving the FEHB Program If you are in your second or third trimester your new plan will
pay for the OB GYN care you receive from your current provider until the end of your postpartum care
How do you 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 it
medical follows generally accepted medical practice
services
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 6
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Section 3 How To Get Benefits continued
How do you Services or supplies including treatments procedures hospitalizations drugs biological products or medical
decide if a devices are considered experimental or investigation if a Peer Review Panel determines the services or supplies are
service is 1 not of proven benefit for the particular diagnosis or treatment of the covered person's particular condition 2 not
experimental or generally recognized by the medical community as effective or appropriate for the particular diagnosis or treatment
investigational of the covered person's particular condition or 3 provided or performed in special settings for research purposes or under a controlled environment or clinical protocol
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 to a membership services representative
2 Refer to specific brochure wording in explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were
unable to make a timely request due to reasons beyond your control
We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30 days
after we receive the additional information If we do not receive the requested information within 60 days we will make our decision
based on the information we already have
When may I ask OPM You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal OPM will
to review a denial determine if we correctly applied the terms of our contract when we denied your claim or request for service
What if I have a Call us at 800 850 8585 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 so
denied my request for that they can give your claim expedited treatment too Alternatively you can call OPM's health benefits
care and my condition Division 3 at 202 606 0755 between 8 a m and 5 p m Serious or life threatening conditions are ones that
is serious or life may cause permanent loss of bodily functions or death if they are not treated as soon as possible
threatening
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Section 4 What To Do If We Deny Your Claim Or Request For Service continued Are there other time You must write to OPM and ask them to review our decision within 90 days after we uphold our initial denial
limits 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 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
Where should I mail Send your request for review to Office of Personnel Management Office of Insurance Programs Contract
my disputed claim to Division 3 P O Box 436 Washington D C 20044
OPM
What if OPM upholds OPM's decision is final There are no other administrative appeals If OPM agrees with our decision your
the Plan's denial only recourse is to sue
If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third year
after the year in which you received the disputed services or supplies
What laws apply if I Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its review
file a lawsuit on the record that was before OPM when OPM made its decision on your claim You may recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment services
supplies or drugs covered by us until you have completed the OPM review procedure described above
Your records and 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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 8
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Section 5 Benefits
Medical Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits you pay a 10 office visit copay but no
additional copay for laboratory tests and X rays Within the service area house calls will be provided if in
the judgment of the Plan doctor such care is necessary and appropriate you pay a 5 copay for a doctor's
house call and you pay nothing for home visits by nurses and health aides
The following services are included and subject to the office visit copay unless stated otherwise
Preventive care including well baby care and periodic check ups
Mammograms are covered as follows for women age 35 through age 39 one mammogram during these five years for women age 40 through 49 one mammogram every one or two years for women age 50
through 64 one mammogram every year and for women age 65 and above one mammogram every two
years In addition to routine screening mammograms are covered when prescribed by the doctor as
medically necessary to diagnose or treat your illness
Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor covered in full after you pay an initial 5 copayment The mother at her option
may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a caesarean delivery
Inpatient stays will be extended if medically necessary If enrollment in the Plan is terminated during
pregnancy benefits will not be provided after coverage under the Plan has ended Ordinary nursery care of
the newborn child during the covered portion of the mother's hospital confinement for maternity will be
covered under either a Self Only or Self and Family enrollment other care of an infant who requires
definitive treatment will be covered only if the infant is covered under a Self and Family enrollment
Voluntary sterilization and family planning services including Norplant
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing and treatment materials such as allergy serum you pay a 5 copay per visit for allergy testing You pay a 5 copay per visit for allergy injections given in a
physician's office office visit copay may apply You pay nothing for allergy serum
The insertion of internal prosthetic devices such as pacemakers cochlear implants and artificial joints
Cornea heart kidney kidney pancreas lung single and double and liver transplants allogeneic donor bone marrow transplants autologous bone marrow transplants autologous stem cell and peripheral stem
cell support for the following conditions acute lymphocytic or non lymphocytic leukemia advanced
Hodgkin's lymphoma advanced non Hodgkin's lymphoma advanced neuroblastoma breast cancer
multiple myeloma epithelial ovarian cancer and testicular mediastinal retroperitoneal and ovarian germ
cell tumors Transplants are covered when approved by the Medical Director 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 have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure
Dialysis
Chemotherapy radiation therapy and inhalation therapy
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Medical Surgical Benefits continued Home use of intravenous fluids and injectable medications such as chemotherapy and intravenous
antibiotics
Injections administered in a physician's office you pay a 5 copay per injection Office visit copay may apply
Surgical treatment of morbid obesity
Home health services of nurses and health aides including fluids and medications when prescribed by your Plan doctor who will periodically review the program for continuing appropriateness and need
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers at no additional cost to you except where noted
Durable medical equipment such as wheelchairs and hospital beds you pay 10 coinsurance
Prosthetic devices such as artificial limbs you pay 10 coinsurance
Orthopedic devices such as braces you pay 10 coinsurance
Plan approved diabetes self management training and education including nutrition therapy
Plan approved periodic early detection women's services including bone density testing for women age 35 and older
Plan approved diagnosis and treatment of endometriosis and endometritis
Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or surgical procedures occurring within
or adjacent to the oral cavity or sinuses including but not limited to treatment of fractures and excision of
tumors and cysts All other procedures involving the teeth or intra oral areas surrounding the teeth are not
covered including any dental care involved in treatment of temporomandibular joint TMJ pain dysfunction
syndrome
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 Breast reconstruction surgery and correction of
breast size disproportion or dissymetry will also be provided following a mastectomy that resulted from breast
cancer
A patient and their attending physician will decide whether or not to have breast reconstruction surgery
following a mastectomy including whether or not to have surgery on the other breast in order to produce a
symmetrical appearance We will provide benefits for all stages of breast reconstruction following a
mastectomy We will also provide benefits for surgery and reconstruction of the other breast in order to
produce a symmetrical appearance We will cover the treatment of any physical complications from the
mastectomy including lymphedemas
We will also provide you with a breast prosthesis including the surgical bra used for an external prosthesis
following a mastectomy In addition to the initial prosthesis following the mastectomy we will provide
necessary replacement prostheses and bras
Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or
outpatient basis for up 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 functioning in other activities of daily living
Diagnosis and treatment of infertility are covered you pay 50 coinsurance The following types of
artificial insemination are covered intravaginal insemination IVI intracervical insemination ICI and
intrauterine insemination IUI you pay 50 coinsurance cost of donor sperm is not covered Fertility
drugs are covered you pay 5 for a 31 day supply Other assisted reproductive technology ART
procedures such as in vitro fertilization and embryo transfer are not covered
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 10
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Medical Surgical Benefits continued Limited benefits Chiropractic services for back treatment you pay a 10 copay per visit up to 30 visits all charges
continued thereafter
Cardiac rehabilitation following a heart transplant bypass surgery or myocardial infarction provided up to
30 sessions You pay 10 per session
What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance attending school or camp or travel
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Transplants not listed as covered
Blood and blood derivatives not replaced by the member
Hearing aids
Long term rehabilitative therapy
Homemaker services
Foot orthotics
Removal of implanted time release medications such as Norplant if removal is elected within three years of the implantation
Hospital Extended Care Benefits What is covered
Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan doctor You pay nothing All necessary services are covered including
Semiprivate room accommodations when a Plan doctor determines it is medically necessary the doctor may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units
Extended care The Plan provides a comprehensive range of benefits for up to 60 days per 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 doctor and approved by the Plan You pay nothing All necessary services are covered
including
Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan doctor
Hospice care Supportive and palliative care for a terminally ill member is covered in the home or hospice facility Services
include inpatient and outpatient care and family counseling these services are provided under the direction of
a Plan doctor who certifies that the patient is in the terminal stages of illness with a life expectancy of
approximately six months or less
Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
Limited benefits Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need for
procedures hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the hospitalization but not the cost of the professional dental services Conditions for which hospitalization would be covered
include hemophilia and heart disease the need for anesthesia by itself is not such a condition
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Hospital Extended Care Benefits continued Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis treatment of
detoxification medical conditions and medical management of withdrawal symptoms acute detoxification if the Plan doctor determines that outpatient management is not medically appropriate See page 14 for nonmedical
substance abuse benefits
What is not covered Personal comfort items such as telephone and television Blood and blood derivatives not replaced by the member
Custodial care rest cures domiciliary or convalescent care
Emergency Benefits What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe
emergency endangers your life or could result in serious injury or disability and requires immediate medical or surgical care Some problems are emergencies because if not treated promptly they might become more serious
examples include deep cuts and broken bones Others are emergencies because they are potentially life
threatening such as heart attacks strokes poisonings gunshot wounds or sudden inability to breathe There
are many other acute conditions that the Plan may determine are medical emergencies what they all have in
common is the need for quick action
Emergencies within If you are in an emergency situation please call you primary care doctor In extreme emergencies if you are
the service area unable to contact your doctor contact the local emergency system e g the 911 telephone system or go to the nearest hospital emergency room Be sure to tell the emergency room personnel that you are a Plan
member so they can notify the Plan You or a family member must notify the Plan within 48 hours unless it is
not reasonably possible to do so It is your responsibility to ensure that the Plan has been timely notified
If you need to be hospitalized in a non Plan facility the Plan must be notified within 48 hours or on the first
working day following your admission unless it was not reasonably possible to notify the Plan within that
time If you are hospitalized in non Plan facilities and Plan doctors believe care can be better provided in a
Plan hospital you will be transferred when medically feasible with ambulance charges for that transfer
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 provided or
directed by your PCP or approved in advance by the Plan
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 25 per hospital emergency room visit or 5 per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in an inpatient admission to a hospital the emergency
care copay is waived
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 12
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Emergency Benefits continued Emergencies Benefits are available for any medically necessary health service that is immediately required because of
outside the service injury or unforeseen illness
area If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to notify the Plan within that time If a Plan doctor
believes care can be better provided in a Plan hospital you will be transferred when medically feasible with
ambulance charges for that transfer covered in full
To be covered by this Plan any follow up care recommended by non Plan providers must be provided or
directed by your PCP or approved in advance by the Plan
Plan pays Reasonable charges for emergency care services to the extent the services would have been covered if received from Plan providers
You pay 25 per hospital emergency room visit or 5 per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in an inpatient admission to a hospital the emergency
care copay is waived
What is covered Emergency care at a doctor's office or an urgent care center Emergency care as an outpatient or inpatient at a hospital including doctor's 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
Medical and hospital costs resulting from a normal full term delivery of a baby outside the service area
Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency care upon
non Plan providers receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form If you are required to pay for the services submit itemized bills and your receipts to the Plan along with an explanation
of the services and the identification information from your ID card Payment will be sent to you or the
provider if you did not pay the bill unless the claim is denied If it is denied you will receive notice of the
decision including the reasons for the denial and the provisions of the contract on which denial was based If
you disagree with the Plan's decision you may request reconsideration in accordance with the disputed claims
procedure described on page 7
Mental Conditions Substance Abuse Benefits Mental conditions
What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions including the treatment of mental illness or disorders
Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Plan approved treatment of Autism including therapeutic respite and rehabilitative care for a child 2 through 21 years of age covered under the plan up to a 500 maximum monthly benefit per child
Outpatient care Up to 30 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year you pay a 10 copay per visit
Inpatient care Up to 30 days of hospitalization each calendar year you pay nothing Inpatient days may be exchanged for outpatient day treatment at the rate of two treatment days for each inpatient day You pay nothing for
outpatient day treatment days that are substituted for inpatient days
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Mental Conditions Substance Abuse Benefits continued What is not covered Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to
significant improvement through relatively short term treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless determined by a Plan doctor to be necessary and appropriate
Psychological testing that is not medically necessary to determine the appropriate treatment of a short term psychiatric condition
Substance abuse What is covered This Plan provides medical and hospital services such as acute detoxification services for the medical
non psychiatric aspects of substance abuse including alcoholism and drug addiction the same as for any
other illness or condition and to the extent shown below the services necessary for diagnosis and treatment
Outpatient care Up to 30 outpatient visits to Plan providers for treatment each calendar year you pay a 10 copay per visit
Inpatient care Up to 30 days per calendar year in a substance abuse rehabilitation intermediate care program in an alcohol detoxification or rehabilitation center approved by the Plan you pay nothing Inpatient days may be
exchanged for outpatient day treatment at the rate of two treatment days for each inpatient day You pay
nothing for outpatient day treatment days that are substituted for inpatient days
What is not covered Treatment that is not authorized by a Plan doctor
Prescription Drug Benefits What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed
for up to a 31 day supply you pay a 5 copay per prescription unit or refill for up to a 31 day supply
You pay a 5 copay per prescription unit or refill for generic drugs or for name brand drugs when generic
substitution is not permissible When generic substitution is permissible i e a generic drug is available and
the prescribing doctor does not require the use of a name brand drug but you request the name brand drug
you pay the difference between the generic and name brand drug as well as the 5 copay per prescription or
refill
Drugs prescribed by Plan doctors are dispensed in accordance with the Plan's drug formulary Nonformulary
drugs will be covered when prescribed by a Plan doctor
Covered medications and accessories include
Drugs for which a prescription is required by Federal law
Oral and injectable contraceptive drugs contraceptive diaphragms
Insulin a copay applies to each vial Coverage includes plan approved supplies and medications necessary for the treatment of insulin dependent diabetes insulin using diabetes and non insulin using
diabetes if prescribed by a health care provider
Disposable needles and syringes needed to inject covered prescribed medication including insulin
Fertility drugs you pay 5 copay per prescription or refill A Plan authorization is required
Intravenous fluids and medication for home use implantable drugs such as Norplant and some injectable drugs are covered under Medical and Surgical Benefits
Drugs to treat sexual dysfunction
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 14
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Prescription Drug Benefits continued What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent 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
Contraceptive devices
Drugs for cosmetic purposes
Smoking cessation drugs and medications including nicotine patches
Drugs to enhance athletic performance
Other Benefits
Dental care Restorative services and supplies necessary to promptly repair but not replace sound natural teeth The need Accidental injury for these services must result from an accidental injury You pay nothing
benefit
Vision care What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye
annual eye refractions to provide a written lens prescription for eyeglasses may be obtained from
participating providers annually for members under age 18 every two years for members 18 years and older
You pay a 10 copay per visit
What is not covered Corrective lenses or frames Eye exercises
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Non FEHB Benefits Available to Plan Members The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made available
to all enrollees and family members 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
Dental Plan This year Advantage Care offers its members the opportunity to add comprehensive dental coverage with DeltaPreferred Option This
Preferred Provider Organization PPO plan features a large panel of dentists plus the option to receive care from out of network
providers
DeltaPreferred Option is an optional benefit with an additional premium that is paid directly to Delta Dental To enroll in this Delta Dental
plan you must be enrolled in Advantage Care and complete and sign the Delta Dental enrollment form There is no initial payment or
enrollment fee All payments must be made to Delta Dental through monthly bank drafts or annual payment in full
The following benefits are available each calendar year
NETWORK OUT OF NETWORK
DEDUCTIBLE 25 Individual 50 Individual
75 Family 150 Family
MAXIMUM BENEFITS
per covered person each benefit year 1,000 1,000
COVERED SERVICES
Diagnostic and Preventative Oral exam emergency exam 100 of Allowable Amount 80 of Allowable Amount
palliative emergency treatment periapical x rays Deductible does not apply Subject to deductible
bitewing x rays panoramic or complete series topical
fluoride application prophylaxis sealants space maintainers
Basic and Major Restorative Services Routine fillings 50 of Allowable Amount 40 of Allowable Amount
simple extractions root canal therapy oral surgery Subject to deductible Subject to deductible
periodontic services simple prosthetic repair prosthetic
services inlays and crowns not a part of a bridge
Dentists who have signed a participating agreement with DeltaPreferred Option agree to accept the Allowable Amount as payment in full for Covered Services Each Covered Person is responsible for the amount of Coinsurance Deductible and non covered charges
Certain procedures require preauthorization and or are subject to limitations No benefits are provided for prosthodontic services related to teeth missing or lost prior to enrollment in this dental plan
This is not a contract It is a partial list of benefits and services For complete details refer to your certificate
Health and Wellness Discounts Special prices are available for fitness programs and services at participating fitness centers Advantage Care members can use these
services for a healthy lifestyle
Optical Discounts Advantage Care members can obtain prescription eyeglasses at discounted rates at participating locations Routine eye exams by
participating ophthalmologists and optometrists are already covered by your Advantage Care plan
All discounts and providers are subject to change at any time without notice For a complete listing of participating health and wellness centers and optical locations see the Discounts section of the provider directory
Benefits on this page are not part of the FEHB contract
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 16
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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 doctor determines it is medically necessary to prevent diagnose or treat your illness or condition
We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits or eligible self referred services
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
Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan
Section 7 Limitations Rules That Affect Your Benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible
for paying for medical services and we will coordinate the payments On occasion you may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a 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 tell
insurance us if you or a family member has double coverage You must also send us documents about other insurance if we
coverage 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
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Section 7 Limitations Rules That Affect Your Benefits continued 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
When others are When you receive money to compensate you for medical or hospital care for injuries or illness that another person
responsible for caused you must reimburse us for whatever services we paid for We will cover the cost of treatment that exceeds
injuries 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 pays
Government for
Agencies
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 18
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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 right to
information about information about your health plan its networks providers and facilities You can also find out about care
your HMO management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's website www opm gov lists the
specific types of information that we must make available to you
If you want specific information about us call 800 850 8585 or write to 120 Prosperous Place Suite 300
Lexington Kentucky 40509 You may also contact us by fax at 606 264 4664 or visit our website at
www advantagecare com
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal Employees
information about Health Benefits Plans brochures for other plans and other materials you need to make an informed decision
enrolling in the FEHB about
Program When you may change your enrollment
How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter military service or retire
When your enrollment ends and
The next Open Season for enrollment
We don't determine who is eligible for coverage and in most cases cannot change your enrollment status
without information from your employing or retirement office
When are my benefits 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 I When you retire you can usually stay in the FEHB Program Generally you must have been enrolled in the
retire FEHB Program for the last five years of your Federal service If you do not meet this requirement you may be eligible for other forms of coverage such as Temporary Continuation of Coverage which is described
later in this section
What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and your unmarried
coverage are dependent children under age 22 including any foster or step children your employing or retirement office
available for me and authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22
my family years of age or older who is incapable of self support
If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry give birth
or add a child to your family You may change your enrollment 31 days before to 60 days after you give birth
or add the child to your family The benefits and premiums for your Self and Family enrollment begin on the
first day of the pay period in which the child is born or becomes an eligible family member
Your employing or retirement office will not notify you when a family member is no longer eligible to receive
health benefits nor will we Please tell us immediately when you add or remove family members from your
coverage for any reason including divorce
If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled in
another FEHB plan
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Section 8 FEHB Facts continued Are my medical and We will keep your medical and claims information confidential Only the following will have access to it
claims records
confidential OPM this Plan and subcontractors when they administer this contract This plan and appropriate third parties such as other insurance plans and the Office of Workers
Compensation Programs OWCP when coordinating benefit payments and subrogating claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions
OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your identity or
OPM when reviewing a disputed claim or defending litigation about a claim
Information For New Members Identification We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF 2809
cards 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 enrolled
conditions 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
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 your
spouse coverage 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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 20
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When You Lose Benefits continued
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 in If you are 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 You may convert to an individual policy if
to individual Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not pay
coverage your premium you cannot convert You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is available You
must apply in writing to us within 31 days after you receive this notice However if you are a family member
who is losing coverage the employing or retirement office will not notify you You must apply in writing to
us within 31 days after you are no longer eligible for coverage
Your benefits and rates will differ from those under the FEHB Program however you will not have to answer
questions about your health and we will not impose a waiting period or limit your coverage due to preexisting
conditions
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When You Lose Benefits continued
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that indicates
Certificate of how long you have been enrolled with us You can use this certificate when getting health insurance or other
Group Health Plan health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new
Coverage 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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 22
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Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for services you
did not receive billed you twice for the same service or misrepresented any information do the following
Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 800 850 8585 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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Summary of Benefits for Advantage Care Inc 2000 Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set
forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or change your
enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of this
brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY CARE ARE
COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS
Benefits Plan pays provides Page
Inpatient Hospital Comprehensive range of medical and surgical services without 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 nothing 11
Extended care All necessary services up to 60 days per calendar year You pay nothing 11
Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per
conditions year You pay nothing You pay nothing for outpatient day treatment days that are exchanged
for inpatient days 13
Substance abuse Up to 30 days per year in a substance abuse treatment program You pay nothing You pay
nothing for outpatient day treatment days that are exchanged for inpatient days 14
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 a 10 copay per
office visit copays are waived for maternity care after initial 5 copay 5 copay per house call by
a doctor 9,10
Home health care All necessary visits by nurses and health aids You pay nothing 10
Mental Up to 30 outpatient visits per year You pay a 10 copay per visit 13
conditions
Substance abuse Up to 30 outpatient visits per year You pay a 10 copay per visit 14
Emergency Reasonable charges for services and supplies required because of medical emergency You pay a
care 25 copay to the hospital for each emergency room visit and any charges for services that are not
covered by this Plan 12,13
Prescription Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5 copay per
drugs prescription unit or refill 14,15
Dental care Accidental injury benefit you pay nothing 15
Vision care One refraction annually for members under age 18 one refraction every two years for members
18 years and older You pay a 10 copay per visit 15
Out of pocket Your out of pocket expenses for benefits under this Plan are limited to 1,000 individual and
maximum 2,000 family in a calendar year for covered services After the out of pocket maximum is
satisfied the Plan pays 100 if eligible expenses for covered services Expenses that apply to the
out of pocket maximum are copayments and coinsurances for covered services except infertility
Expenses that do not apply to the out of pocket maximum are coinsurance for infertility services
charges in excess of eligible expenses and all expenses for non covered services 5
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 24
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2000 Rate Information for
Advantage Care Inc
Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the FEHB Guide for that
category or contact the agency that maintains your health benefits enrollment
Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates referred to as Category A
rates and Category B rates will apply for certain career employees If you are a career postal employee but not a member of a special
postal employment class refer to the category definitions in The Guide to Federal Employees Health Benefits Plans for United States
Postal Service Employees RI 70 2 to determine which rate applies to you
Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes or associate members of
any postal employee organization Such persons not subject to postal rates must refer to the applicable Guide to Federal Employees
Health Benefits Plans
Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Code Gov't Your Gov't Your USPS Your USPS Your
Enrollment Share Share Share Share Share Share Share Share
Central Eastern Kentucky
Self Only XW1 70.52 23.50 152.78 50.93 83.44 10.58 83.44 10.58
Self and Family XW2 175.97 68.26 381.27 147.90 207.74 36.49 201.02 43.21
25 26