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CompcareBlue www. compcare. uwz. com (formerly known as Compcare Health Services)
2001
A Health Maintenance Organization

Serving: Southeast, Northcentral and Northwestern Wisconsin
Enrollment in this Plan is limited; see page 7 for requirements.

Southeastern Wisconsin enrollment codes:
691 Self Only 692 Self and Family

Northcentral and Northwestern enrollment codes:
6X1 Self Only 6X2 Self and Family

Authorized for distribution by the:
United States Office of Personnel Management
Retirement and Insurance Service http:// www. opm. gov/ insure RI 71-xxx

RI 73-022

OPM
Logo 1
1 Page 2 3
2001 CompcareBlue 2 Table of Contents
Table of Contents
Introduction................................................................. 4
Plain Language;................................................................ 4
Section 1. Facts about this HMO plan ........................................................................................................................... 5
How we pay providers .................................................................................................................................. 5
Who provides my healthcare? 5
Patients' Bill of Rights .................................................................................................................................. 6
Service Area.................................................................................................................................................. 7
Section 2. How we change for 2001.. ................................................................ 9
Program-wide changes.................................................................................................................................. 9
Section 3. How you get care;... .................................................................................................................... 10
Identification cards...................................................................................................................................... 10
Where you get covered care........................................................................................................................ 10
· Plan providers ....................................................................................................................................... 10
· Plan facilities ........................................................................................................................................ 10
What you must do to get covered care........................................................................................................ 10

· Primary care.......................................................................................................................................... 10
· Specialty care........................................................................................................................................ 10
· Hospital care ......................................................................................................................................... 11
Circumstances beyond our control.............................................................................................................. 12
Services requiring our prior approval ......................................................................................................... 12
Section 4. Your costs for covered services .................................................................................................................. 13

· Copayments .......................................................................................................................................... 13
· Deductible............................................................................................................................................. 13
· Coinsurance .......................................................................................................................................... 13
Your out-of-pocket maximum .................................................................................................................... 13
Section 5. Benefits; ............................................................... 14
Overview..................................................................................................................................................... 14
(a) Medical services and supplies provided by physicians and other health care professionals ........... 15
(b) Surgical and anesthesia services provided by physicians and other health care professionals........ 24
(c) Services provided by a hospital or other facility, and ambulance services...................................... 28
(d) Emergency services/ accidents.......................................................................................................... 31
(e) Mental health and substance abuse benefits..................................................................................... 34
(f) Prescription drug benefits................................................................................................................. 36
(g) Special features ................................................................................................................................ 39
(h) Dental benefits.................................................................................................................................. 40
(i) Non-FEHB benefits available to Plan members .............................................................................. 41
Section 6. General exclusions --things we don't cover .............................................................................................. 42 2
2 Page 3 4
2001 CompcareBlue 3 Table of Contents
Section 7. Filing a claim for covered services ............................................................................................................. 43
Section 8. The disputed claims process........................................................................................................................ 44
Section 9. Coordinating benefits with other coverage ................................................................................................. 46
When you haveÉ
·Other health coverage .......................................................................................................................... 46
·Original Medicare ................................................................................................................................ 46
·Medicare managed care plan ............................................................................................................... 48
TRICARE/ Workers' Compensation/ Medicaid............................................................................................ 49
Other Government agencies........................................................................................................................ 50
When others are responsible for injuries..................................................................................................... 50
Section 10. Definitions of terms we use in this brochure ............................................................................................ 51
Section 11. FEHB facts ................................................................................................................................................ 52

Coverage information.................................................................................................................................. 52
· No pre-existing condition limitation................................................................................................... 52
· Where you get information about enrolling in the FEHB Program.................................................... 52
· Types of coverage available for you and your family ........................................................................ 52
· When benefits and premiums start...................................................................................................... 53
· Your medical and claims records are confidential.............................................................................. 53
· When you retire.................................................................................................................................. 53
When you lose benefits ............................................................................................................................... 53

· When FEHB coverage ends................................................................................................................ 53
· Spouse equity coverage...................................................................................................................... 53
· Temporary Continuation of Coverage (TCC).................................................................................... 53
Converting to individual coverage ................................................................................................................................ 54
Getting a Certificate of Group Health Plan Coverage .................................................................................................. 54
Inspector General Advisory .......................................................................................................................................... 54
Index ................................................................................................................................................................. 55
Summary of benefits ..................................................................................................................................................... 56
RatesÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉ.. Back cover 3
3 Page 4 5
2001 CompcareBlue 4 Introduction/ Plain Language
Introduction
CompcareBlue
401 W. Michigan Street
Milwaukee, WI 53203

This brochure describes the benefits of CompcareBlue under our contract (CS1361) with the Office of Personnel
Management (OPM), as authorized by the Federal Employees Health Benefits law. This brochure is the official
statement of benefits. No oral statement can modify or otherwise affect the benefits, limitations, and exclusions of
this brochure.

If you are enrolled in this Plan, you are 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. You do not have a right to
benefits that were available before January 1, 2001, unless those benefits are also shown in this brochure.

OPM negotiates benefits and rates with each plan annually. Benefit changes are effective January 1, 2001, and are
summarized on page 9. Rates are shown 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. In response, a team of health plan
representatives and OPM staff worked cooperatively to make this brochure clearer. Except for necessary technical
terms, we use common words. "You" means the enrollee or family member; "we" means CompcareBlue.

The plain language team reorganized the brochure and the way we describe our benefits. When you compare this Plan
with other FEHB plans, you will find that the brochures have the same format and similar information to make
comparisons easier.

If you have comments or suggestions about how to improve this brochure, let us know. Visit OPM's "Rate Us"
feedback area at www. opm. gov/ insure or e-mail us at fehbwebcomments@ opm. gov or write to OPM at Insurance
Planning and Evaluation Division, P. O. Box 436, Washington, DC 20044-0436. 4
4 Page 5 6
2001 CompcareBlue 5 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and
other providers that contract with us. These Plan providers coordinate your health care services.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in
addition to treatment for illness and injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.

When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay
the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from
non-Plan providers, 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.

How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These
Plan providers accept a negotiated payment from us, and you will only be responsible for your copayments or
coinsurance.

Who provides my healthcare?
CompcareBlue is a mix of both medical groups and individual doctors. In Burlington, Janesville, Racine, Sheboygan,
Waukesha, and West Bend, the Plan has medical groups. In Milwaukee and the Northcentral and Northwestern
regions, the Plan has both medical groups and individual doctors. Each medical group consists of doctors from
different specialties who practice in a common center or centers. The individual doctors are generally available to
Plan members in groupings commonly known as Individual Practice Associations (IPAs), which consist of doctors of
different specialties who practice in their own offices.

The first and most important decision each member must make is the selection of a primary care doctor. The decision
is important since it is through this doctor that all other health services, particularly those of specialists, are obtained.
It is the responsibility of your primary care doctor to obtain any necessary authorizations from the Plan before
referring you to a specialist or making arrangements for hospitalization. See "What you must do to get covered
Specialty care" below for services that you can receive without a referral from your primary care doctor.

Please note:
§ If you want to enroll in a certain medical group or IPA, you must reside within the area in which that group or
IPA practices. For example, the Milwaukee area providers (IPA doctors and medical groups) are available only
to people who live in the enrollment area for the Milwaukee region shown on page 7. The areas in which the
various Plan providers practice and are available for selection are shown in detail in the Plan's provider directory.
§ Members within the same family may choose physicians from different networks. For example, a member can
belong to one medical group/ IPA, a spouse can belong to a different medical group/ IPA and a child can belong to
yet another medical group/ IPA.

Our provider directory lists primary care doctors (family practitioners, pediatricians and internists), with their
locations and phone numbers, and notes whether or not the doctor is accepting new patients. Directories are updated
on a regular basis and are available at the time of enrollment or upon request by calling the Member Services
Department at 1-800-492-4049 or 414-276-2273 in the Southeast region; by calling 1-800-258-5299 in the
Northcentral region; or by calling 1-800-368-4453 in the Northwestern region; you can also find out if your doctor
participates with our Plan by calling these numbers. 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 in the Plan and is accepting new
patients. 5
5 Page 6 7
2001 CompcareBlue 6 Section 1
Important note: When you enroll in our Plan, services (except for emergency benefits) are provided through the
Plan's delivery system; the continued availability and/ or participation of any one doctor, hospital, or other
provider cannot be guaranteed.

If you enroll, you will be asked to let us know which primary care doctor( s) you've selected for you and each member
of your family by sending a selection form to us. If you need help in choosing a doctor, call us. Members may
change their doctor selection by notifying us 30 days in advance.

If you are receiving services from a doctor who leaves the Plan, we will pay for covered services until we can arrange
with you for you to be seen by another participating doctor.

Patients' Bill of Rights
OPM requires that all FEHB Plans comply with the Patients' Bill of Rights recommended by the President's Advisory
Commission on Consumer Protection and Quality in the Health Care Industry. You may get information about your
health plan, its networks, providers, and facilities. OPM's FEHB website (www. opm. gov/ insure) lists the specific
types of information that we must make available to you. Some of the required information is listed below.

· Compliance with State licensing requirements · Years in existence
· Profit status
If you want more information about us, call 1-800-492-4049 or 414-276-22273 in the Southeastern region; 1-800-258-
5299 in the Northcentral region; or 1-800-368-4453 in the Northwestern region; or write to CompcareBlue 401 W.
Michigan Street, Milwaukee, WI 53203. You may also contact us by fax at 414-226-2636 or visit our website at
www. compcare. uwz. com. 6
6 Page 7 8
2001 CompcareBlue 7 Section 1
Service Area
To enroll with us, you must live in our service area. This is where our providers practice. Our service area is:
Southeastern Region:
Milwaukee area: The counties of Milwaukee, Ozaukee, Racine, Washington, and Waukesha. Also portions of Dodge, Fond du Lac, Jefferson, Kenosha, Racine,
Sheboygan, and Walworth counties denoted by the zip codes on page 7.

Waukesha area: The counties of Milwaukee and Waukesha. Also portions of Dodge, Jefferson, Ozaukee, Racine, Walworth and Washington counties denoted by the zip codes
on page 7.

West Bend area: The counties of Ozaukee and Washington. Also portions of Dodge, Fond du Lac, Jefferson, Sheboygan, and Waukesha counties denoted by the zip codes on
page 8.

Janesville area: Rock County. Also portions of Dane, Green, Jefferson, Racine, and Walworth counties denoted by the zip codes on page 8.

Racine area: Racine and Kenosha Counties, Milwaukee County south of the I-94
East/ West Expressway. Also portions of Walworth and Waukesha counties denoted by the
zip codes on page 8.

Burlington area: Portions of Kenosha, Milwaukee, Racine, Walworth, and Waukesha counties denoted by the zip codes on page 8.

Sheboygan area: Brown, Sheboygan and Manitowoc Counties. Also portions of Fond du
Lac, Ozaukee, and Washington counties denoted by zip codes on page 8.

Northcentral Region:

The counties of Clark, Forest, Langlade, Lincoln, Marathon, Oneida, Portage, Shawano, Taylor, Vilas, Waupaca and Wood.

Northwestern Region:
The counties of Ashland, Bayfield, Burnett, Douglas, Iron, Pepin, Pierce, Polk, Price,
Sawyer, St. Croix, and Washburn.

You may also enroll with us if you live or work in the following zip code locations:
Southeastern Region:
Milwaukee area:
53002-04 53027 53075 53105 53148-49 53176-77
53010 53036 53091 53118-20 53152 53182
53013 53040 53101 53138-39 53159 53403
53021 53066

Waukesha area:
53003 53036-38 53092 53120-21 53150 53182
53012 53047 53094-95 53126 53156 53185
53017 53059-60 53103 53130 53157 53190
53022 53066 53105 53137 53176 53538
53027 53076-78 53108 53138-39 53178 53549
53033-34 53086 53118-19 53148-49 7
7 Page 8 9
2001 CompcareBlue 8 Section 1
West Bend area:
53001-07 53023 5303940 5305960 53077-79 53099
53009-11 53026-27 53043 553064-66 53085 53209
53013 53029 53046-48 53070 53087 53217-18
53016-17 5303l-32 53050-51 53072-73 53089-91 53219
53021 53034-36 53056-57 53075 53093-94 53223-25
53935

Janesville area:
53114-15 53138 53180 53502 53538 53574-75
53120-21 53147-48 53184-85 53508 53549-50 53585
53125 53156-57 53190-91 53520-21 53566 53589
53128 53176 53195 53523 53570
53570

Racine area:
53103 53120 53130 53148-50 53157 53176
53105 53128 53138

Burlington area:
53101 53120-21 53138-39 53159 53176 53185
53104-05 53125-26 53147-50 53167-68 53179 53191-92
53108-09 53128 53152 53170 53181-82 53194
53115 53130 53157

Sheboygan area:
53004 53021 53040 53057 53060-62 53079

Northcentral Region 54401 54439-43 54462-3 54484-5 54548 54566
54403 54445-49 54465-7 54487-90 54554 54568
54405-14 54451-52 54469-71 54531 54558 54746
54418-28 54454-57 54473-6 54539-41 54561-2 54776
54433-37 54460 54479-81

Northwestern Region:
54514 54546-7 54814 54834-6 54859 54880
54517 54550 54816-7 54838-9 54861-2 54888
54525 54559 54820-1 54842-7 54864-5 54890-1
54527-8 54565 54827-8 54849-50 54867 54893
54534 54801 54832 54854-6 54870-6 54896
54536 54806

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, particularly those of
specialists, unless they are obtained through your Primary Care Physician. Chiropractic services, oral surgery and
mental health and substance abuse services are covered without a referral when performed by one of our Plan
providers.

If you or a covered family member reside/ live 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), they may be able to receive
benefits under our Away From Home Care guest membership program. This program provides care for routine,
follow-up urgent and emergency situations just as your home Plan does. Contact our Customer Services Department
for information on how to access and use the Away From Home Care guest membership program. 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. 8
8 Page 9 10
2001 CompcareBlue 9 Section 2
Section 2. How we change for 2001
Program-wide changes
· The plain language team reorganized the brochure and the way we describe our benefits. We hope this will make it easier for you to compare plans.

· This year, the Federal Employees Health Benefits Program is implementing network mental health and substance abuse parity. This means that your coverage for mental health, substance abuse, medical, surgical, and hospital
services from providers in our plan network will be the same with regard to deductibles, coinsurance, copays, and
day and visit limitations when you follow a treatment plan that we approve. Previously, we placed shorter day or
visit limitations on mental health and substance abuse services than we did on services to treat physical illness,
injury, or disease.

· Many healthcare organizations have turned their attention this past year to improving healthcare quality and patient safety. OPM asked all FEHB plans to join them in this effort. You can find specific information on our

patient safety activities by calling our Member Services Department at the phone numbers listed on page 5. You
can find out more about patient safety on the OPM website, www. opm. gov/ insure. To improve your healthcare,
take these five steps:

·· Speak up if you have questions or concerns.
·· Keep a list of all the medicines you take.
·· Make sure you get the results of any test or procedure.
·· Talk with your doctor and health care team about your options if you need hospital care.
·· Make sure you understand what will happen if you need surgery.
· We clarified the language to show that anyone who needs a mastectomy may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure. Previously, the

language referenced only women.
Changes to this Plan
· CODE 69 Your share of the non-Postal premium will increase by

87.8% for Self Only or 65. 0% for Self and Family.
CODE 6X
Your share of the non-Postal premium will increase by
44.7 % for Self Only or 21.7 % for Self and Family.

· Brown County has been added to the Plan's service area.
· Compcare Health Services now utilizes the trade name CompcareBlue. 9
9 Page 10 11
2001 CompcareBlue 10 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you
receive services from a Plan provider, or fill a prescription at a Plan
pharmacy. Until you receive your ID card, use your copy of the Health
Benefits Election Form, SF-2809, your health benefits enrollment
confirmation (for annuitants), or your Employee Express confirmation
letter.

If you do not receive your ID card within 30 days after the effective date of
your enrollment, or if you need replacement cards, call the Member
Services Department at 1-800-492-4049 or 414-276-2273 in the Southeast
region; 1-800-258-5299 in the Northcentral region; or 1-800-368-453 in
the Northwestern region.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments or coinsurance, and you will not have to file claims.
When you receive emergency services you may have to submit claim
forms (See "Emergency services/ accidents").

Plan providers Plan providers are physicians and other health care professionals in our
service area that we contract with to provide covered services to our
members. We credential Plan providers according to national standards.

We list Plan providers in the provider directory, which we update
periodically. The list is also on our website.

Plan facilities Plan facilities are hospitals and other facilities in our service area that we
contract with to provide covered services to our members. We list these in
the provider directory, which we update periodically. The list is also on our
website.

What you must do
to get covered care It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is important since

your primary care physician provides or arranges for most of your health
care

Primary care Your primary care physician can be a family practitioner, internist or
pediatrician. Your primary care physician will provide most of your health
care, or give you a referral to see a specialist (See "Who provides my
health care?" for more details).

If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us. We will help you select a new one.

Specialty care Your primary care physician will refer you to a specialist for needed care.
However, you may receive the following services from a Plan provider
without a referral: chiropractic services, oral surgery, mental health, and
substance abuse services. A woman may also select an
obstetrician/ gynecologist as her secondary primary care physician; this
selection must be made from her primary care physician's medical group
or IPA. A woman may see her Plan obstetrician/ gynecologist for her
annual routine examination without a referral. 10
10 Page 11 12
2001 CompcareBlue 11 Section 3
When you receive a referral from your primary care physician, you return
to the primary care physician after the consultation unless your physician
authorizes additional visits. All follow-up care must be provided or
authorized by the primary care physician. Do not go to the specialist for a
second visit unless your primary care physician has arranged for, and we
have issued an authorization for, the referral in advance.

Here are other things you should know about specialty care:
· If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will develop
a treatment plan that allows you to see your specialist for a certain
number of visits without additional referrals. Your primary care
physician will use our criteria when creating your treatment plan (the
physician may have to get an authorization or approval beforehand).

· If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what
treatment you need. If he or she decides to refer you to a specialist, ask
if you can see your current specialist. If your current specialist does not
participate with us, you must receive treatment from a specialist who
does. Generally, we will not pay for you to see a specialist who does
not participate with our Plan.

· If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another
specialist. You may receive services from your current specialist until
we can make arrangements for you to see someone else.

· If you have a chronic or disabling condition and lose access to your specialist because we:

·· terminate our contract with your specialist for other than cause; or
·· drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan; or

·· reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days
after you receive notice of the change. Contact us or, if we drop out of
the Program, contact your new plan.

If you are in the second or third trimester of pregnancy and you lose access
to your specialist based on the above circumstances, you can continue to
see your specialist until the end of your postpartum care, even if it is
beyond the 90 days.

Hospital care Your Plan primary care physician or specialist will make necessary
hospital arrangements and supervise your care. This includes admission to
a skilled nursing or other type of facility.

If you are in the hospital when your enrollment in our Plan begins, call our
Customer Service Department immediately at 1-800-492-4049 or 414-276-
2273 in the Southeast region; 1-800-258-5299 in the Northcentral region;
or 1-800-368-453 in the Northwestern. If you are new to the FEHB
Program, we will arrange for you to receive care. 11
11 Page 12 13
2001 CompcareBlue 12 Section 3
If you changed from another FEHB plan to us, your former plan will pay
for the hospital stay until:

· You are discharged, not merely moved to an alternative care center; or
· The day your benefits from your former plan run out; or
· The 92 nd day after you become a member of this Plan, whichever happens first.

These provisions apply only to the benefits of the hospitalized person.
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them. In
that case, we will make all reasonable efforts to provide you with the
necessary care.

Services requiring our
prior approval Your primary care physician has authority to refer you for most services. For certain services, however, your physician must obtain approval from

us. Before giving approval, we consider if the service is covered,
medically necessary, and follows generally accepted medical practice.

We call this review and approval process pre-authorization. Your
physician must obtain our approval before sending you to the hospital,
referring you to a specialist, or recommending follow-up care.

We will ask you to submit information that establishes that the service is
medically necessary. If you do not ask or we determine that the service is
not medically necessary, we will not cover the service or related services
and supplies. 12
12 Page 13 14
2001 CompcareBlue 13 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider when
you receive services.

Example: When you see your primary care physician you pay a
copayment of $10 per office visit and when you go in the hospital, you pay
$100 per admission.

Deductible A deductible is a fixed expense you must incur for certain covered services
and supplies before we start paying benefits for them. We have no
deductibles.

NOTE: If you change plans during open season, you do not have to start a
new deductible under your old plan between January 1 and the effective
date of your new plan. If you change plans at another time during the year,
you must begin a new deductible under your new plan.

And, if you change options in this Plan during the year, we will credit the
amount of covered expenses already applied toward the deductible of your
old option to any deductible of your new plan.

Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for
your care.

Example: In our Plan, you pay 50% of charges for fertility drugs after the
$2,000 per member infertility treatment limit is reached.

Your out-of-pocket maximum We have no out-of-pocket maximum.
for deductibles, coinsurance,
and copayments 13
13 Page 14 15
2001 CompcareBlue 14 Section 5
Section 5. Benefits --OVERVIEW
(See page 9 for how our benefits changed this year and page 56 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at
the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact us
at 1-800-492-4049 or 414-276-2273 in the Southeast region; by calling 1-800-258-5299 in the Northcentral region; or
by calling 1-800-368-453 in the Northwestern region or at our website at www. compcare. uwz. com.

(a) Medical services and supplies provided by physicians and other health care professionalsÉÉÉÉÉÉ.. 15-23

·Diagnostic and treatment services ·Lab, X-ray, and other diagnostic tests
·Preventive care, adult ·Preventive care, children
·Maternity care ·Family planning
·Infertility services ·Allergy care
·Treatment therapies ·Rehabilitative therapies

·Hearing services (testing, treatment and supplies)
·Vision services (testing, treatment and supplies) ·Foot care
·Orthopedic and prosthetic devices ·Durable medical equipment (DME)
·Home health services ·Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals ....................... 24-27
·Surgical procedures ·Reconstructive surgery ·Oral and maxillofacial surgery ·Organ/ tissue transplants
·Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services ..................................................... 28-30

·Inpatient hospital ·Outpatient hospital or ambulatory surgical
center
·Extended care benefits/ skilled nursing care facility benefits
·Hospice care ·Ambulance

(d) Emergency services/ accidents ......................................................................................................................... 31-33
·Medical emergency ·Ambulance

(e) Mental health and substance abuse benefits .................................................................................................... 34-35
(f) Prescription drug benefits ................................................................................................................................ 36-38
(g) Special features...................................................................................................................................................... 39

(h) Dental benefits ....................................................................................................................................................... 40
(i) Non-FEHB benefits available to Plan members.................................................................................................... 41

Summary of benefits ..................................................................................................................................................... 56 14
14 Page 15 16
2001 CompcareBlue 15 Section 5( a)
Section 5 (a) Medical services and supplies provided by physicians and
other health care professionals

I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
· Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

· Plan physicians must provide or arrange your care.
· We have no calendar year deductible.
· Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.

I M
P O
R T
A N
T

Benefit Description You pay
Diagnostic and treatment services
Professional services of physicians or chiropractors
· In physician's or chiropractor's office

$10 per office visit

Professional services of physicians
· In an urgent care center
· During a hospital stay
· In a skilled nursing facility
· Initial examination of a newborn child covered under a family enrollment

· Office medical consultations
· Second surgical opinion

$10 per office visit

Professional services of physicians
· In an outpatient treatment facility
$25 per office visit

Professional services of physicians
· At home
$10 per office visit 15
15 Page 16 17
2001 CompcareBlue 16 Section 5( a)
Lab, X-ray and other diagnostic tests You pay
Tests, such as:
· Blood tests
· Urinalysis
· Non-routine pap tests
· Pathology
· X-rays
· Non-routine Mammograms
· CAT Scans/ MRI
· Ultrasound
· Electrocardiogram and EEG

$10 per office visit

Preventive care, adult You pay
Routine screenings, such as:
· Blood lead level Ð One annually
· Total Blood Cholesterol Ð once every three years, ages 19 through 64
· Colorectal Cancer Screening, including
··Fecal occult blood test

$10 per office visit

··Sigmoidoscopy, screening Ð every five years starting at age 50 $10 per office visit
Prostate Specific Antigen (PSA test) Ð one annually for men age 40 and older $10 per office visit
Routine pap test
Note: The office visit is covered if pap test is received on the same day;
see Diagnostic and Treatment, above.

$10 per office visit

Routine mammogram Ðcovered for women age 35 and older, as
follows:

· From age 35 through 39, one during this five year period
· From age 40 through 64, one every calendar year
· At age 65 and older, one every two consecutive calendar years

$10 per office visit

Not covered: Physical exams required for obtaining or continuing
employment or insurance, attending schools or camp, or travel.
All charges.

· Routine Immunizations $10 per office visit

Preventive care, children You pay
· Childhood immunizations recommended by the American Academy of Pediatrics $10 per office visit 16
16 Page 17 18
2001 CompcareBlue 17 Section 5( a)
Preventive care, children (Continued) You pay
· Examinations, such as:
··Eye exams through age 17 to determine the need for vision correction.

··Ear exams through age 17 to determine the need for hearing correction
··Examinations done on the day of immunizations ( through age 22)
· Well-child care charges for routine examinations, immunizations and care (through age 22)

$10 per office visit

Maternity care You pay
Complete maternity (obstetrical) care, such as:
· Prenatal care
· Delivery
· Postnatal care
Note: Here are some things to keep in mind:

· You do not need to precertify your normal delivery.
· You may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery. We will extend

your inpatient stay if medically necessary.
· We cover routine nursery care of the newborn child during the covered portion of the mother's maternity stay. We will cover other

care of an infant who requires non-routine treatment only if we
cover the infant under a Self and Family enrollment.

· We pay hospitalization and surgeon services (delivery) the same as for illness and injury. See Hospital benefits (Section 5c) and

Surgery benefits (Section 5b).

Nothing.

Not covered: Routine sonograms to determine fetal age, size or sex All charges
Family planning You pay
· Voluntary sterilization
· Surgically implanted contraceptives
· Injectable contraceptive drugs
· Intrauterine devices (IUDs)
Note: We cover contraceptive drugs and devices under the prescription
drug benefit.

$10 per office visit 17
17 Page 18 19
2001 CompcareBlue 18 Section 5( a)
Family planning (Continued) You pay
Not covered: reversal of voluntary surgical sterilization, genetic
counseling,
All charges.

Infertility services You pay
Diagnosis and treatment of infertility, such as:
· Artificial insemination:
··intravaginal insemination (IVI)
··intracervical insemination (ICI)
··intrauterine insemination (IUI)
· Fertility drugs
Note: We cover injectable fertility drugs under medical benefits and oral
fertility drugs under the prescription drug benefit.

Nothing for first $2,000 in charges
per member for the first treatment
program. You pay 50% of charges
after you pay the first $2,000 for
all infertilty services you receive
while covered by us.

Not covered:
· Assisted reproductive technology (ART) procedures, such as:
··in vitro fertilization
··embryo transfer and GIFT
· Services and supplies related to excluded ART procedures

· Cost of donor sperm

All charges.

Allergy care You pay
Testing and treatment
Allergy injection
$10 per office visit

Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy
desensitization
All charges. 18
18 Page 19 20
2001 CompcareBlue 19 Section 5( a)
Treatment therapies You pay
· Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone
marrow transplants are limited to those transplants listed under
Organ/ Tissue Transplants on page 27.

· Respiratory and inhalation therapy
· Dialysis Ð Hemodialysis and peritoneal dialysis
· Intravenous (IV)/ Infusion Therapy Ð Home IV and antibiotic therapy

· Growth hormone therapy (GHT)

$10 per office visit 19
19 Page 20 21
2001 CompcareBlue 20 Section 5( a)
Rehabilitative therapies You pay
· Physical therapy, occupational therapy and speech therapy
· Cardiac rehabilitation Phase I and II following a heart transplant, bypass surgery or a myocardial infarction
$10 per office visit

Nothing

Not covered:
· long-term rehabilitative therapy
· exercise programs

All charges.

Hearing services (testing, treatment, and supplies) You pay
· Hearing testing for children through age 17 (see Preventive care, children) $10 per office visit

Not covered:
· all other hearing testing · hearing aids, testing and examinations for them All charges. 20
20 Page 21 22
2001 CompcareBlue 21 Section 5( a)
Vision services (testing, treatment, and supplies) You pay
Diagnosis and treatment of diseases of the eye; eye exams and
refractions as medically necessary.
$10 per office visit

· Eye exam to determine the need for vision correction for children through age 17 (see preventive care) $10 per office visit

Not covered:
· Corrective lenses or frames
· Eyeglasses or contact lenses and, after age 17, examinations for them

· External lenses following cataract removal
· Eye exercises and orthoptics
· Radial keratotomy and other refractive surgery

All charges.

Foot care You pay
Routine foot care when you are under active treatment for a metabolic
or peripheral vascular disease, such as diabetes.

See orthopedic and prosthetic devices for information on podiatric shoe
inserts.

$10 per office visit

Not covered:
· Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot,

except as stated above
· Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the

treatment is by open cutting surgery)

All charges. 21
21 Page 22 23
2001 CompcareBlue 22 Section 5( a)
Orthopedic and prosthetic devices You pay
· Artificial limbs and eyes; stump hose
· Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

· Internal prosthetic devices, such as artificial joints, pacemakers, cochlear implants, and surgically implanted breast implant
following mastectomy. Note: See 5( b) for coverage of the surgery
to insert the device.

· Corrective orthopedic appliances for non-dental treatment of temporomandibular joint (TMJ) pain dysfunction syndrome.

$25 copay per person per calendar
year (Combined with DME)

Not covered:
· orthopedic and corrective shoes
· arch supports
· foot orthotics
· heel pads and heel cups
· lumbosacral supports
· corsets, trusses, elastic stockings, support hose, and other supportive devices

· prosthetic replacements that are not medically necessary

All charges.

Durable medical equipment (DME) You pay
Rental or purchase, at our option, including repair and adjustment, of
durable medical equipment prescribed by your Plan physician, such as
oxygen and dialysis equipment. Under this benefit, we also cover:

· hospital beds;
· wheelchairs
· crutches;
· walkers;
· blood glucose monitors; and
· one insulin pump per calendar year for diabetes is covered under this benefit provided you use it successfully for 30 days prior to

coverage.

$25 copay per person per calendar
year (Combined with Prosthetics)

Not covered:
· Motorized wheel chairs All charges. 22
22 Page 23 24
2001 CompcareBlue 23 Section 5( a)
Home health services You pay
· Home health care ordered by a Plan physician and provided by a registered nurse (R. N.), licensed practical nurse (L. P. N.), licensed

vocational nurse (L. V. N.), or home health aide.
· Services include oxygen therapy, intravenous therapy and medications.

$10 per office visit

Home health services (Continued) You pay
Not covered:
· nursing care requested by, or for the convenience of, the patient or the patient's family;

· nursing care primarily for hygiene, feeding, exercising, moving the patient, homemaking, companionship or giving oral medication.

All charges.

Educational classes and programs You pay
Coverage is limited to:

· Diabetes self-management
$10 per office visit 23
23 Page 24 25
2001 CompcareBlue 24 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other
health care professionals

I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
· Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

· Plan physicians must provide or arrange your care.
· We have no calendar year deductible.
· Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other coverage, including with

Medicare.
· The amounts listed below are for the charges billed by a physician or other health care professional for your surgical care. Look in Section 5 ( c ) for charges associated with the facility (i. e. hospital,

surgical center, etc.) are covered in Section 5 (c).
· YOU MUST GET PRECERTIFICATION OF SOME SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require precertification

and identify which surgeries require precertification.

I M
P O
R T
A N
T

Benefit Description You pay
Surgical procedures
· Treatment of fractures, including casting · Normal pre-and post-operative care by the surgeon

· Correction of amblyopia and strabismus · Endoscopy procedure
· Biopsy procedure · Removal of tumors and cysts
· Correction of congenital anomalies (see reconstructive surgery) · Surgical treatment of morbid obesity --a condition in which an
individual weighs 100 pounds or 100% over his or her normal
weight according to current underwriting standards; eligible
members must be age 18 or over

· Insertion of internal prosthetic devices. See 5( a) Ð Orthopedic braces and prosthetic devices for device coverage information.

$10 per visit

Surgical procedures continued on next page. 24
24 Page 25 26
2001 CompcareBlue 25 Section 5( b)
Surgical procedures (Continued) You pay
· Voluntary sterilization · Norplant (a surgically implanted contraceptive) and intrauterine

devices (IUDs) Note: Devices are covered under 5( a).
· Treatment of burns

Note: Generally, we pay for internal prostheses (devices) according to
where the procedure is done. For example, we pay Hospital benefits for
a pacemaker and Surgery benefits for insertion of the pacemaker.

$10 per visit

Not covered:
· Reversal of voluntary sterilization · Routine treatment of conditions of the foot; see Foot care. All charges.

Reconstructive surgery You pay
· Surgery to correct a functional defect
· Surgery to correct a condition caused by injury or illness if:
··the condition produced a major effect on the member's appearance and

··the condition can reasonably be expected to be corrected by such surgery
· Surgery to correct a condition that existed at or from birth and is a significant deviation from the common form or norm. Examples of
congenital anomalies are: protruding ear deformities; cleft lip; cleft
palate; birth marks; webbed fingers; and webbed toes.

$10 per visit

· All stages of breast reconstruction surgery following a mastectomy, such as:
·· surgery to produce a symmetrical appearance on the other breast;
·· treatment of any physical complications, such as lymphedemas;
·· breast prostheses and surgical bras and replacements (see Prosthetic devices)

Note: If you need a mastectomy, you may choose to have the procedure
performed on an inpatient basis and remain in the hospital up to 48
hours after the procedure

$10 per visit

Not covered:
· Cosmetic surgery Ð any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance

through change in bodily form, except repair of accidental injury
· Surgeries related to sex transformation

All charges

Oral and maxillofacial surgery You pay 25
25 Page 26 27
2001 CompcareBlue 26 Section 5( b)
Oral surgical procedures, limited to:
· Reduction of fractures of the jaws or facial bones; · Surgical correction of cleft lip, cleft palate or severe functional
malocclusion;
· Removal of stones from salivary ducts; · Excision of leukoplakia or malignances;

· Excision of cysts and incision of abscesses when done as independent procedures; and
· Other surgical procedures that do not involve the teeth or their supporting structures

Nothing

Not covered:
· Oral implants and transplants · Procedures that involve the teeth or their supporting structures (such

as the periodontal membrane, gingival, and alveolar bone)
· All other procedures involving the teeth or intra-oral areas surrounding the teeth not specifically mentioned above.

All charges. 26
26 Page 27 28
2001 CompcareBlue 27 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
· Cornea
· Heart
· Heart/ lung
· Single lung
· Double lung
· Kidney
· Liver
· Pancreas

· Allogeneic (donor) bone marrow transplants
· Autologous bone marrow transplants with high doses chemotherapy (ABMT/ HDC) are covered for breast cancer, multiple myeloma, epithelial
ovarian cancer, testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors.

· Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) are covered for the following conditions: acute
lymphocytic or non-lymphocytic leukemia, advanced Hodgkin's
lymphoma, advanced non-Hodgkin's lymphoma, advanced neuroblastoma

Nothing

We cover related medical and hospital expenses of the donor when we
cover the recipient

20% of charges.

Not covered:
· Donor screening tests and donor search expenses, except those performed for the actual donor

· Implants of artificial organs
· Transplants not listed as covered

All charges

Anesthesia You pay
Professional services provided in Ð

· Hospital (inpatient) · Hospital outpatient department
· Skilled nursing facility · Ambulatory surgical center
· Office

$10 per visit 27
27 Page 28 29
2001 CompcareBlue 28 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and
ambulance services

I M
P O
R T
A N
T

Here are some important things to remember about these benefits:
· Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are

medically necessary.
· Plan physicians must provide or arrange your care and you must be hospitalized in a Plan facility.

· We have no calendar year deductible
· Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about

coordinating benefits with other coverage, including with Medicare.
· The amounts listed below are for the charges billed by the facility (i. e., hospital or surgical center) or ambulance service for your surgery or care. Any costs

associated with the professional charge (i. e., physicians, etc.) are covered in
Section 5( a) or (b).

I M
P O
R T
A N
T

Benefit Description You pay
Inpatient hospital
Room and board, such as
· ward, semiprivate, or intensive care accommodations; · general nursing care; and

· meals and special diets.

NOTE: If you want a private room when it is not medically necessary,
you pay the additional charge above the semiprivate room rate.

$100 per admission, up to an
annual maximum of $200 per
member per year.

Inpatient hospital continued on next page. 28
28 Page 29 30
2001 CompcareBlue 29 Section 5( c)
Inpatient hospital (Continued) You pay
Other hospital services and supplies, such as:
· Operating, recovery, maternity, and other treatment rooms · Prescribed drugs and medicines

· Diagnostic laboratory tests and X-rays · Administration of blood and blood products
· Blood or blood plasma, if not donated or replaced · Dressings, splints, casts, and sterile tray services
· Medical supplies and equipment, including oxygen · Anesthetics, including nurse anesthetist services
· Take-home items · Medical supplies, appliances, medical equipment, and any covered
items billed by a hospital for use at home

Nothing

Not covered:
· Custodial care, rest cures, domiciliary or convalescent care · Non-covered facilities, such as nursing homes, extended care

facilities, schools
· Personal comfort items, such as telephone, television, barber services, guest meals and beds

· Private nursing care

All charges.

Outpatient hospital or ambulatory surgical center You pay
· Operating, recovery, and other treatment rooms · Prescribed drugs and medicines
· Diagnostic laboratory tests, X-rays, and pathology services · Administration of blood, blood plasma, and other biologicals
· Blood and blood plasma, if not donated or replaced · Pre-surgical testing
· Dressings, casts, and sterile tray services · Medical supplies, including oxygen
· Anesthetics and anesthesia service
NOTE: Ð We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do not cover the dental procedures.

$25 per visit

Not covered: blood and blood derivatives not replaced by the member All charges
Extended care benefits/ skilled nursing care facility benefits You pay
Covered for up to 30 days per member per 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 us. All necessary services are covered,
including:
· Bed, board and general nursing care · Biologicals, supplies, and equipment ordinarily provided or

arranged by the skilled nursing facility when prescribed by a Plan
doctor. Drugs are covered under the prescription drug benefit.

Nothing 29
29 Page 30 31
2001 CompcareBlue 30 Section 5( c)
Extended care benefits/ skilled nursing care facility benefits
(Continued)
You pay

Not covered: custodial care, rest cures, domiciliary or convalescent
care
All charges

Hospice care You pay
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 six months or less.

Nothing

Ambulance You pay
· Local professional ambulance service when medically appropriate $25 per occurrence 30
30 Page 31 32
2001 CompcareBlue 31 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
· Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure.

· We have no calendar year deductible.
· Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.

I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe
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 we may determine are medical emergencies Ð what
they all have in common is the need for quick action.

What to do in case of emergency:
Emergencies within our service area: If you are in an emergency situation, please call your primary care physician. In extreme emergencies, if you are unable to contact your doctor, contact the local
emergency system (e. g., the 911 telephone system) or go the nearest hospital emergency room. Be sure to
tell the emergency room personnel that you are a Plan member so they can notify us. You or a family
member must notify your Plan primary care physician within 48 hours or on the first working day
following your admission to arrange follow-up care, unless it is not reasonably possible to do so. It is
your responsibility to ensure that your primary care physician has been timely notified.

If you need to be hospitalized, we must be notified within 48 hours or on the first working day following
your admission, unless it is not reasonably possible to notify us within that time. If you are hospitalized
in non-Plan facilities and Plan doctors believe care can be better provided in a Plan hospital, you will be
transferred when medically feasible with any ambulance charges covered in full.

Benefits are available for care from non-Plan providers in a medical emergency only if delay in reaching
a Plan provider would result in death, disability or significant jeopardy to your condition.

For services to be covered by this Plan, any follow-up care recommended by non-Plan providers must be
approved by us or provided by Plan providers.

We pay reasonable charges for emergency services to the extent the services would have been covered if
received from Plan providers.

You pay $25 per member per hospital emergency room visit or urgent care center visit for emergency
services which are covered benefits of the Plan. Inpatient admissions are subject to the hospital copay of
$100 per admission, up to an annual maximum of $200 per member per year. If you are admitted as an
inpatient, the $25 copayment will be waived and the inpatient copayment will be apply. If you have met
your annual maximum, the $25 copayment will apply.

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

If you need to be hospitalized, we must be notified within 48 hours or on the first working day following
your admission, unless it is not reasonably possible to notify us within that time. If you are hospitalized 31
31 Page 32 33
2001 CompcareBlue 32 Section 5( d)
in non-Plan facilities and Plan doctors believe care can be better provided in a Plan hospital, you will be
transferred when medically feasible with any ambulance charges covered in full.

For services to be covered by this Plan, any follow-up care recommended by non-Plan providers must be
approved by us or provided by Plan providers.

We pay reasonable charges for emergency services to the extent the services would have been covered if
received from Plan providers.

You pay $25 per member per hospital emergency room visit or urgent care center visit for emergency
services which are covered benefits of the Plan. Inpatient admissions are subject to the hospital copay of
$100 per admission, up to an annual maximum of $200 per member per year. If you are admitted as an
inpatient, the $25 copayment will be waived and the inpatient copayment will be apply. If you have met
your annual maximum, the $25 copayment will apply.

Filing claims for non-Plan providers: With your authorization, we will pay benefits directly to the providers of your emergency room care upon receipt of their claims. Physician claims should be
submitted on the HCFA 1500 claim form. If you are required to pay for the services, submit itemized bills
and your receipts to us 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 reason for the denial. If you
disagree with our decision, you may request reconsideration in accordance with the disputed claims
procedure described on page 44. 32
32 Page 33 34
2001 CompcareBlue 33 Section 5( d)
Benefit Description You pay
Emergency within our service area

· Emergency care at a doctor's office $10 per office visit
· Emergency care at an urgent care center or hospital emergency room

Note: $25 copayment is waived if you are admitted as an inpatient.
Inpatient admission will be subject to the $100 per admission copay. If
the annual maximum is met, the $25 copayment will apply.

$25 per visit

Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area You pay
· Emergency care at a doctor's office $10 per office visit

· Emergency care at an urgent care center or hospital emergency room
Note: $25 copayment is waived if you are admitted as an inpatient.
Inpatient admission will be subject to the $100 inpatient copayment. If
the annual copayment maximum is met, the $25 copayment will apply.

$25 per visit

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

All charges.

Ambulance You pay
Professional local ambulance service when medically appropriate.
See 5( c) for non-emergency service.
$25 per occurrence 33
33 Page 34 35
2001 CompcareBlue 34 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
P O
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A N
T

Parity
Beginning in 2001, all FEHB plans' mental health and substance abuse benefits will achieve
"parity" with other benefits. This means that we will provide mental health and substance abuse
benefits differently than in the past.

When you get our approval for services and follow a treatment plan we approve, cost-sharing
and limitations for Plan mental health and substance abuse benefits will be no greater than for
similar benefits for other illnesses and conditions.

Here are some important things to keep in mind about these benefits:
· All benefits are subject to the definitions, limitations, and exclusions in this brochure.
· We have no calendar year deductible. For facility care, the inpatient admission copay applies to some benefits in this Section. We indicate where the inpatient admission copay

applies.
· Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.
· YOU MUST GET PREAUTHORIZATION OF THESE SERVICES. See the instructions after the benefits description below.

I M
P O
R T
A N
T

Benefit Description You pay
Mental health and substance abuse benefits
All diagnostic and treatment services recommended by a Plan provider
and contained in a treatment plan that we approve. The treatment plan
may include services, drugs, and supplies described elsewhere in this
brochure.

Note: Plan benefits are payable only when we determine the care is
clinically appropriate to treat your condition and only when you receive
the care as part of a treatment plan that we approve.

Your cost sharing
responsibilities are no
greater than for other illness
or conditions.

· Professional services, including individual or group therapy by
providers such as psychiatrists, psychologists, or clinical social
workers

· Medication management

$10 per office visit

Mental health and substance abuse benefits -Continued on next page 34
34 Page 35 36
2001 CompcareBlue 35 Section 5( e)
Mental health and substance abuse benefits (Continued) You pay
· Diagnostic tests $10 per office visit

· Services provided by a hospital or other facility
· Services in approved alternative care settings such as partial
hospitalization, half-way house, residential treatment, full-day
hospitalization, facility based intensive outpatient treatment

$100 copay per inpatient
admission, up to an annual
maximum of $200 per member
per year.

Not covered: Services we have not approved.
Note: OPM will base its review of disputes about treatment plans
on the treatment plan's clinical appropriateness. OPM will
generally not order us to pay or provide one clinically appropriate
treatment plan in favor of another.

All charges.

Preauthorization We do not require preauthorization, but we strongly recommend that your provider seek preauthorization prior to rendering services
.

Special transitional benefit If a mental health or substance abuse professional provider is treating you under our plan as of January 1, 2001, you will be eligible for
continued coverage with your provider for up to 90 days under the
following condition:

· If your mental health or substance abuse professional provider with whom you are currently in treatment leaves the plan at our request for
other than cause.

If this condition applies to you we will allow you reasonable time to
transfer your care to a Plan mental health or substance abuse
professional provider. During the transitional period, you may continue
to see your treating provider and will not pay any more out-of-pocket than
you did in the year 2000 for services. This transitional period will begin
with our notice to you of the change in coverage and will end 90 days
after you receive our notice. If we write to you before October 1, 2000,
the 90-day period ends before January 1 and this transitional benefit does
not apply.

Limitation We may limit your benefits if you do not follow your treatment plan. 35
35 Page 36 37
2001 CompcareBlue 36 Section 5( f)
Section 5 (f). Prescription drug benefits
I
M
P
O
R
T
A
N
T

Here are some important things to keep in mind about these benefits:
· We cover prescribed drugs and medications, as described in the chart beginning on the next page.

· All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
· We have no calendar year deductible.
· Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other

coverage, including with Medicare.

I
M
P
O
R
T
A
N
T

There are important features you should be aware of. These include:
· Who can write your prescription. A licensed Plan physician or a referral physician must write the prescription .

· Where you can obtain them. You must fill the prescription at a plan pharmacy, or by mail if necessary. Call 1-800-522-3636 for more information regarding mail order pharmacy benefits.
· We use a formulary. Drugs are prescribed by Plan doctors and dispensed in accordance with our managed care formulary. We make the determination to include/ exclude specific drugs on our
formulary based on: medical policy on therapy protocols; and managed formulary decisions such as
identical products or drugs considered less than effective. Should a physician ask for prior approval
or a denied drug claim is appealed, our Pharmacy Services department will request patients' medical
and pharmacy history and will request a physician consultant's opinion. A full medical review will
be done if necessary.

· These are the dispensing limitations. Prescription drugs prescribed by a Plan or referral physician and obtained at a Plan pharmacy will be dispensed for up to a 34-day supply. You pay a $7 copay per

prescription unit or refill for up to a 34-day supply or 100-unit supply, whichever is less; 240 milliliters
of liquid ( 8 oz) ; 60 grams of ointment creams or topical preparation; or one commercially prepared
unit (i. e., one inhaler, one vial ophthalmic medication or insulin) for generic drugs or $12 for name
brand drugs when generic substitution is not permissible or available.

· When you have to file a claim. Plan pharmacies will file the claim directly with us.

Prescription drug benefits begin on the next page. 36
36 Page 37 38
2001 CompcareBlue 37 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy:
· Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase.

· Insulin; with a copay charge per vial · Diabetic supplies including insulin syringes, needles, glucose test
tablets and test tape. Benedicts solution or equivalent gluclose monitor
supplies and acetone test tablets; one month supply of each item
purchased at one time may be obtained for one copay.
· Disposable needles and syringes needed to inject covered prescribed medication

· Full range of FDA approved drugs, prescriptions and devices for birth control; injectable contraceptive drugs (subject to the office visit
copay); Norplant is covered; you pay nothing for the implantation
You must pay the cost of its removal if, for whatever reason, the
Norplant is surgically removed before three years have elapsed from
the date of its insertion.
· Nitroglycerin, phenobarbital or Thyroid U. S. P. · Intravenous fluids and medication for home use

· Drugs to treat sexual dysfunction are limited. Contact us for dose limits. You pay the applicable copayment up to the dosage limits and
all charges thereafter.
Note: The following drugs are only available through the designated Plan
pharmacy:

· Self-injectable medications (except for insulin, glucagon, epinephrine kits, and Imitrex)
· Prescriptions which exceed $150 in cost · Growth hormones
· Fertility drugs (you pay 50% of charges after the $2,000 per member infertility treatment limit is reached. See page 18)
· A 90-day supply of maintenance drugs. You pay three copays.

$ 7 per prescription unit or refill
for generic drugs

$ 12 per prescription unit or refill
for name brand drugs

Note: If there is no generic equivalent
available, you will still have to pay the
brand name copay. 37
37 Page 38 39
2001 CompcareBlue 38 Section 5( f)
Covered medications and supplies (continued) You pay
Here are some things to keep in mind about our prescription drug
program:

· A generic equivalent will be dispensed if it is available, unless your physician specifically requires a name brand. If you receive a
name brand drug when a Federally-approved generic drug is
available, and your physician has not specified Dispense as Written
for the name brand drug, you have to pay the difference in cost
between the name brand drug and the generic.

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
· Drugs and supplies for cosmetic purposes
· Drugs to enhance athletic performance
· Smoking cessation drugs and medications, including nicotine patches

· Non precsription medicines

All Charges 38
38 Page 39 40
2001 CompcareBlue 39 Section 5( g)
Section 5 (g). Special Features
Feature Description
Flexible benefits
option

Under the flexible benefits option, we determine the most effective
way to provide services.

· We may identify medically appropriate alternatives to traditional care and coordinate other benefits as a less costly alternative

benefit.
· Alternative benefits are subject to our ongoing review.
· By approving an alternative benefit, we cannot guarantee you will get it in the future.

· The decision to offer an alternative benefit is solely ours, and we may withdraw it at any time and resume regular contract benefits.
· Our decision to offer or withdraw alternative benefits is not subject to OPM review under the disputed claims process. 39
39 Page 40 41
2001 CompcareBlue 40 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T

Here are some important things to keep in mind about these benefits:
· Please remember that all benefits are subject to the definitions, limitations, and exclusions in this brochure and are payable only when we determine they are medically necessary.

· Plan dentists must provide or arrange your care.
· We have no calendar year deductible.
· We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization medically necessary to safeguard the health of the

patient; we do not cover the dental procedure unless it is described below.
· Be sure to read Section 4, Your costs for covered services for valuable information about how cost sharing works. Also read Section 9 about coordinating benefits with other
coverage, including with Medicare.

I M
P O
R T
A N
T

Accidental injury benefit You pay
We cover restorative services and supplies necessary
to promptly repair (or initially replace) sound natural
teeth are covered. The need for these services must
result from an accidental injury.

20% of covered charges

Teeth extraction benefit
We will cover the extraction of seven or more fully
erupted natural teeth at one time.

We have no other dental benefits

20% of covered charges 40
40 Page 41 42
2001 CompcareBlue 41 Section 5( i)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed
claim about them. Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket
maximums.

Expanded dental
Benefits Choose Dentacare 160 for quality, coverage, convenience and choice.

Valuable dental coverage
· No deductible before benefits begin · No annual dollar maximum
· No claim forms · No waiting periods
· No pre-existing condition limitations · No pre-authorization requirements

Available at low monthly cost
· Only $13.64 for Self Only coverage · Only $39.83 for Self and Family coverage
· Billed directly to you on a quarterly basis
100 percent coverage for preventive and diagnostic care

· 100% for regular exams · 100% for regular cleanings
· 100% for x-rays
60 percent coverage for:

· Restorative Services · Endonics
· Periodontics · Prosthodontics
· Oral Surgery
Orthodontics covered up to 50% up to a lifetime maximum per person of $1,250
(for dependents only through age 19, or age 23 if 50% support and a full-time
student).

Professional care at
Convenient locations
· Over 70 professional dental centers · Locations throughout Wisconsin

· Select the center most convenient for your family · One center services you and all eligible family members
· Evening and Saturday hours at many centers · Each family member chooses own dentist at selected center

For more information Call our customer service department today at 414-226-6744 in Milwaukee or
1-800-242-7312 in Wisconsin 41
41 Page 42 43
2001 CompcareBlue 42 Section 6
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, disease, injury or condition.

We do not cover the following:
· Care by non-Plan providers except for authorized referrals or emergencies (see Emergency Benefits);

· Services, drugs, or supplies you receive while you are not enrolled in this Plan;
· Services, drugs, or supplies that are not medically necessary;
· Services, drugs, or supplies not required according to accepted standards of medical, dental, or psychiatric practice;

· Experimental or investigational procedures, treatments, drugs or devices;
· Services, drugs, or supplies related to abortions, except when the life of the mother would be endangered if the fetus were carried to term;

· Services, drugs, or supplies related to sex transformations;
· Expenses you incurred while you were not enrolled in this Plan; or
· Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program. 42
42 Page 43 44
2001 CompcareBlue 43 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at
Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment,
coinsurance, or deductible.

You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these
providers bill us directly. Check with the provider. If you need to file the claim, here is the process:

Medical and hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form.
Facilities will file on the UB-92 form. For claims questions and
assistance, call us at 1-800-492-4049 or 414-276-2273 in the
Southeastern region; 1-800-258-5299 in the Northcentral region; or 1-
800-368-4453 in the Northwestern region. .

When you must file a claim --such as for out-of-area care --submit it on
the HCFA-1500 or a claim form that includes the information shown
below. Bills and receipts should be itemized and show:

· Covered member's name and ID number;
· Name and address physician or facility that provided the service or supply;

· Dates you received the services or supplies;
· Diagnosis;
· Type of each service or supply;
· The charge for each service or supply;
· A copy of the explanation of benefits, payments, or denial from any primary payer --such as the Medicare Summary Notice
(MSN); and

· Receipts, if you paid for your services.
Submit your claims to: The address on your ID card.

Prescription drugs Submit your claims to: The address on your ID card.
Other supplies or services Submit your claims to: The address on your ID card.
Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you
received the service, unless timely filing was prevented by administrative
operations of Government or legal incapacity, provided the claim was
submitted as soon as reasonably possible.

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 43
43 Page 44 45
2001 CompcareBlue 44 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on
your claim or request for services, drugs, or supplies Ð including a request for preauthorization:

Step Description

1 Ask us in writing to reconsider our initial decision. Write to us at: 401 West Michigan Street, Milwaukee, Wisconsin 53203. You must:
(a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: 401 West Michigan Street, Milwaukee, Wisconsin 53203; and
(c) Include a statement about why you believe our initial decision was wrong, based on specific benefit
provisions in this brochure; and

(d) Include copies of documents that support your claim, such as physicians' letters, operative reports,
bills, medical records, and explanation of benefits (EOB) forms.

2 We have 30 days from the date we receive your request to: (a) Pay the claim (or, if applicable, arrange for the health care provider to give you the care); or
(b) Write to you and maintain our denial --go to step 4; or
(c) Ask you or your provider for more information. If we ask your provider, we will send you a copy of
our requestÑ go to step 3.

3 You or your provider must send the information so that we receive it within 60 days of our request. We will then decide within 30 more days.
If we do not receive the information within 60 days, we will decide within 30 days of the date the
information was due. We will base our decision on the information we already have.

We will write to you with our decision.

4 If you do not agree with our decision, you may ask OPM to review it.
You must write to OPM within:
· 90 days after the date of our letter upholding our initial decision; or
· 120 days after you first wrote to us --if we did not answer that request in some way within 30 days; or
· 120 days after we asked for additional information.

Write to OPM at: Office of Personnel Management, Office of Insurance Programs, Contracts Division III,
P. O. Box 436, Washington, D. C. 20044-0436.

Send OPM the following information:
· A statement about why you believe our decision was wrong, based on specific benefit provisions in this brochure;

· Copies of documents that support your claim, such as physicians' letters, operative reports, bills, medical records, and explanation of benefits (EOB) forms;
· Copies of all letters you sent to us about the claim;
· Copies of all letters we sent to you about the claim; and
· Your daytime phone number and the best time to call.

Note: If you want OPM to review different claims, you must clearly identify which documents apply to
which claim. 44
44 Page 45 46
2001 CompcareBlue 45 Section 8
Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your
representative, such as medical providers, must provide a copy of your specific written consent with the
review request.

Note: The above deadlines may be extended if you show that you were unable to meet the deadline because
of reasons beyond your control.

5 OPM will review your disputed claim request and will use the information it collects from you and us to decide whether our decision is correct. OPM will send you a final decision within 60 days. There are no
other administrative appeals.

6 If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received
the disputed services, drugs or supplies. This is the only deadline that may not be extended.

OPM may disclose the information it collects during the review process to support their disputed claim
decision. This information will become part of the court record.

You may not sue until you have completed the disputed claims process. Further, Federal law governs your
lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of
benefits in dispute.

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily
functions or death if not treated as soon as possible), and

(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at 1-
800-492-4049 or 414-276-2273 in the Southeastern region; 1-800-258-5299 in the Northcentral region; or 1-
800 368-4453 in the Northwestern region and we will expedite our review; or

(b) We denied your initial request for care or preauthorization/ prior approval, then:

·· If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment too, or

·· You can call OPM's Health Benefits Contracts Division III at 202/ 606-0737 between 8 a. m. and 5 p. m. eastern time. 45
45 Page 46 47
2001CompcareBlue 46 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you are covered or a family member is covered under another group health plan or have automobile insurance that pays health
care expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in
full as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is
primary according to the National Association of Insurance
Commissioners' guidelines.

When we are the primary payer, we will pay the benefits described in
this brochure.

When we are the secondary payer, we will determine our allowance.
After the primary plan pays, we will pay what is left of our allowance,
up to our regular benefit. We will not pay more than our allowance.

What is Medicare? Medicare is a Health Insurance Program for:
·· People 65 years of age and older.
·· Some people with disabilities, under 65 years of age.
·· People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant).

Medicare has two parts:
·· Part A (Hospital Insurance). Most people do not have to pay for Part A.
·· Part B (Medical Insurance). Most people pay monthly for Part B.

If you are eligible for Medicare, you may have choices in how you get your health
care. Medicare + Choice is the term used to describe the various health plan
choices available to Medicare beneficiaries. The information in the next few pages
shows how we coordinate benefits with Medicare, depending on the type of
Medicare managed care plan you have.

The Original Medicare Plan The Original Medicare Plan is available everywhere in the United States.
It is the way most people get their Medicare Part A and Part B benefits.
You may go to any doctor, specialist, or hospital that accepts Medicare.
Medicare pays its share and you pay your share. Some things are not
covered under Original Medicare, like prescription drugs.

When you are enrolled in this Plan and Original Medicare, you still need
to follow the rules in this brochure for us to cover your care. For
example, your care must continue to be authorized by your Plan PCP.

We will not waive any of our copayments, coinsurance, and deductibles.
(Primary payer chart begins on next page.) 46
46 Page 47 48
2001CompcareBlue 47 Section 9
The following chart illustrates whether Original Medicare or this Plan should be the primary payer for you according
to your employment status and other factors determined by Medicare. It is critical that you tell us if you or a covered
family member has Medicare coverage so we can administer these requirements correctly.

Primary Payer Chart
Then the primary payer isÉ A. When either you --or your covered spouse --are age 65 or over and É

Original Medicare This Plan
1) Are an active employee with the Federal government (including when you or
a family member are eligible for Medicare solely because of a disability), ü

2) Are an annuitant, ü
3) Are a reemployed annuitant with the Federal government whenÉ ÉÉ.
a) The position is excluded from FEHB, orÉÉÉÉÉÉÉÉÉÉÉÉ ü

b) The position is not excluded from FEHBÉÉÉÉÉÉÉÉÉÉ
Ask your employing office which of these applies to you.
ü

4) Are a Federal judge who retired under title 28, U. S. C., or a Tax
Court judge who retired under Section 7447 of title 26, U. S. C. (or if
your covered spouse is this type of judge),

5) Are enrolled in Part B only, regardless of your employment status, ü (for Part B
services)

ü
(for other
services)

6) Are a former Federal employee receiving Workers' Compensation
and the Office of Workers' Compensation Programs has determined
that you are unable to return to duty,

ü
(except for claims
related to Workers'
Compensation.)

B. When you --or a covered family member --have Medicare
based on end stage renal disease (ESRD) andÉ

1) Are within the first 30 months of eligibility to receive Part A
benefits solely because of ESRD, ü

2) Have completed the 30-month ESRD coordination period and are
still eligible for Medicare due to ESRD, ü

3) Become eligible for Medicare due to ESRD after Medicare became
primary for you under another provision, ü

C. When you or a covered family member have FEHB andÉ
1) Are eligible for Medicare based on disability, and
a) Are an annuitant, or ÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉ ü
b) Are an active employeeÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉÉ É ü 47
47 Page 48 49
2001CompcareBlue 48 Section 9
Claims process --You probably will never have to file a claim form
when you have both our Plan and Medicare.

· When we are the primary payer, we process the claim first.
· When Original Medicare is the primary payer, Medicare processes
your claim first. In most cases, your claims will be coordinated
automatically and we will pay the balance of covered charges. You
will not need to do anything. To find out if you need to do something
about filing your claims, call us at our Member Services Department
phone numbers listed on page 5.

Medicare managed care plan If you are eligible for Medicare, you may choose to enroll in and get your
Medicare benefits from a Medicare managed care plan. These are health
care choices (like HMOs) in some areas of the country. In most
Medicare managed care plans, you can only go to doctors, specialists, or
hospitals that are part of the plan. Medicare managed care plans cover all
Medicare Part A and B benefits. Some cover extras, like prescription
drugs. To learn more about enrolling in a Medicare managed care plan,
contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at
www. medicare. gov. If you enroll in a Medicare managed care plan, the
following options are available to you:

This Plan and our Medicare managed care plan: You may enroll in
our Medicare managed care plan and also remain enrolled in our FEHB
plan. In this case, we do not waive any of our copayments, coinsurance,
or deductibles for your FEHB coverage.

This Plan and another Plan's Medicare managed care plan: You
may enroll in another plan's Medicare managed care plan and also
remain enrolled in our FEHB plan. We will still provide benefits when
your Medicare managed care plan is primary, even out of the managed
care plan's network and/ or service area (if you use our Plan providers),
but we will not waive any of our copayments, coinsurance, or deductibles

Suspended FEHB coverage and a Medicare managed care plan: If
you are an annuitant or former spouse, you can suspend your FEHB
coverage to enroll in a Medicare managed care plan, eliminating your
FEHB premium. (OPM does not contribute to your Medicare managed
care plan premium.) For information on suspending your FEHB
enrollment, 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 unless you involuntarily lose coverage or move out of the
Medicare+ Choice service area.

Enrollment in Note: If you choose not to enroll in Medicare Part B, you can still be
Medicare Part B covered under the FEHB Program. We cannot require you to enroll in
Medicare.

TRICARE TRICARE is the health care program for eligible dependents of military persons and retirees of the military. TRICARE includes the CHAMPUS
program. If both TRICARE and this Plan cover you, we pay first. See
your TRICARE Health Benefits Advisor if you have questions about
TRICARE coverage. 48
48 Page 49 50
2001CompcareBlue 49 Section 9
Workers' Compensation We do not cover services that:
· 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; or

· 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 OWCP or similar agency pays its maximum benefits for your
treatment, we will cover your benefits. You must use our providers.

Medicaid When you have this Plan and Medicaid, we pay first. 49
49 Page 50 51
2001CompcareBlue 50 Section 9
When other Government agencies We do not cover services and supplies when a local, State,
are responsible for your care or Federal Government agency directly or indirectly pays for them.

When others are responsible When you receive money to compensate you for
for injuries medical or hospital care for injuries or illness caused by another person, you must reimburse us for any expenses we paid. However, we will

cover the cost of treatment that exceeds the amount you received in the
settlement.

If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation procedures. 50
50 Page 51 52
2001 CompcareBlue 51 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on
December 31 of the same year.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 13.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 13.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Care which is designed to assist in meeting the activities of daily living and which does not require the continuing attention of trained medical
personnel. It includes services such as help in walking, getting in and out
of bed, assistance in bathing, dressing, feeding and using the toilet.

Experimental or Devices, drugs, biologic products, procedures, programs of diagnosis or
investigational services treatment, and facilities for which there is a lack of scientific evidence permitting conclusions as to the effect of the health outcome; that the net

health outcome is beneficial; that the beneficial outcome is better than
that achieved under established alternatives; and that the effect is
attainable under the usual conditions of medical practice.

Medical necessity Means that the service or supply is: (a.) appropriate and consistent with the symptoms or diagnosis and treatment; (b) in accordance with
standards of good medical practice; (c) not primarily for convenience;
and( d) the most appropriate and least costly supply or level of service
which can be safely provided.

Us/ We Us and we refer to CompcareBlue.
You You refers to the enrollee and each covered family member. 51
51 Page 52 53
2001 CompcareBlue 52 Section 11
Section 11. FEHB facts
No pre-existing condition We will not refuse to cover the treatment of a condition that you had
limitation before you enrolled in this Plan solely because you had the condition before you enrolled.

Where you can get information See www. opm. gov/ insure. Also, your employing or retirement office
about enrolling in the can answer your questions, and give you a Guide to Federal Employees
FEHB Program Health Benefits Plans, brochures for other plans, and other materials you need to make an informed decision about:

· 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
· When the next open season for enrollment begins.
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.

Types of coverage available Self Only coverage is for you alone. Self and Family coverage is for
for you and your family you, your spouse, and your unmarried dependent children under age 22, including any foster children or stepchildren your employing or

retirement office authorizes coverage for. Under certain circumstances,
you may also continue coverage for a disabled child 22 years of age or
older who is incapable of self-support.

If you have a Self Only enrollment, you may change to a Self and Family
enrollment if you marry, give birth, or add a child to your family. You
may change your enrollment 31 days before to 60 days after that event.
The Self and Family enrollment begins on the first day of the pay period
in which the child is born or becomes an eligible family member. When
you change to Self and Family because you marry, the change is effective
on the first day of the pay period that begins after your employing office
receives your enrollment form; benefits will not be available to your
spouse until you marry.

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, or when your child
under age 22 marries or turns 22.

If you or one of your family members is enrolled in one FEHB plan, that
person may not be enrolled in or covered as a family member by another
FEHB plan. 52
52 Page 53 54
2001 CompcareBlue 53 Section 11
When benefits and The benefits in this brochure are effective on January 1. If you are new
premiums start to this Plan, your coverage and premiums begin on the first day of your first pay period that starts on or after January 1. Annuitants' premiums begin on January 1.

Your medical and claims We will keep your medical and claims information confidential. Only
records are confidential the following will have access to it:

· 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.
When you retire When you retire, you can usually stay in the FEHB Program. Generally, you must have been 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 (TCC).

When you lose benefits
When FEHB coverage ends You will receive an additional 31 days of coverage, for no additional
premium, when:

·· Your enrollment ends, unless you cancel your enrollment, or
·· You are a family member no longer eligible for coverage.
You may be eligible for spouse equity coverage or Temporary
Continuation of Coverage.

Spouse equity If you are divorced from a Federal employee or annuitant, you may not
coverage continue to get 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 RI 70-5, the
Guide to Federal Employees Health Benefits Plans for Temporary
Continuation of Coverage and Former Spouse Enrollees, or other
information about your coverage choices.

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 Temporary
Continuation of Coverage (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 or from www. opm. gov/ insure. 53
53 Page 54 55
2001 CompcareBlue 54 Section 11
Converting to You may convert to an non-FEHB individual policy if:
individual coverage ·· Your coverage under TCC or the spouse equity law ends. If you
canceled your coverage or did not pay your premium, you cannot
convert;

·· You decided not to receive coverage under TCC or the spouse equity law; or

·· You are not eligible for coverage under TCC or the spouse equity law.
If you leave Federal service, your employing office will notify you of
your right to convert. You must apply in writing to us within 31 days
after you receive this notice. However, if you are a family member who
is losing coverage, the employing or retirement office will not notify
you. You must apply in writing to us within 31 days after you are no
longer eligible for coverage.

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

Getting a Certificate of If you leave the FEHB Program, we will give you a Certificate of Group
Group Health Plan Coverage Health Plan Coverage that indicates how long you have been enrolled with us. You can use this certificate when getting health insurance or other health care coverage.

Your new plan must reduce or eliminate waiting periods, limitations, or exclusions
for health related conditions based on the information in the certificate, as long as
you enroll within 63 days of losing coverage under this Plan.

If you have been enrolled with us for less than 12 months, but were
previously enrolled in other FEHB plans, you may also request a
certificate from those plans.

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 the Member
Services Department numbers listed on page 5 and explain the
situation.
· If we do not resolve the issue, call THE HEALTH CARE FRAUD HOTLINE--202/ 418-3300 or write to: The United States Office of

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

Penalties for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be
prosecuted for fraud. Also, the Inspector General may investigate
anyone who uses an ID card if the person tries to obtain services for
someone who is not an eligible family member, or is no longer enrolled
in the Plan and tries to obtain benefits. Your agency may also take
administrative action against you. 54
54 Page 55 56
2001CompcareBlue 55 Index
Index
Do not rely on this page; it is for your convenience and does not explain your benefit coverage.
Accidental injury 40 Allergy tests 18
Ambulance 30
Anesthesia 27
Autologous bone marrow
transplant 27
Biopsies 24 Birthing centers 17

Blood and blood plasma 29
Breast cancer screening 16
Casts 24
Changes for 2001 9
Chemotherapy 19
Childbirth 17
Cholesterol tests 16
Circumcision xx
Claims 43
Coinsurance 13
Colorectal cancer screening 16
Congenital anomalies 24
Contraceptive devices and drugs 17
Coordination of benefits 46
Covered charges 10
Crutches 22
Deductible 13 Definitions 51

Dental care 40
Diagnostic services 15
Disputed claims review 44
Donor expenses (transplants) 27
Dressings 29
Durable medical equipment
(DME) 22
Educational classes and programs 23 Emergency 31

Experimental or investigational 42
Eyeglasses 21
Family planning 17 Fecal occult blood test 16

General Exclusions 42 Hearing services 20

Home health services 23
Hospice care 30
Home nursing care 23
Hospital 28
Immunizations 16 Infertility 18

Inhospital physician care 15
Inpatient Hospital Benefits 28
Insulin 37
Laboratory and pathological services 16

Machine diagnostic tests 16 Magnetic Resonance Imagings
(MRIs) 16
Mail Order Prescription Drugs 36
Mammograms 16
Maternity Benefits 17
Medicaid 49
Medically necessary 51
Medicare 46
Mental Conditions/ Substance
Abuse Benefits 34
Newborn care 17
Non-FEHB Benefits 41
Nurse
Licensed Practical Nurse 23
Nurse Anesthetist 27
Psychiatric Nurse 34
Registered Nurse 23
Nursery charges 17
Obstetrical care 17 Occupational therapy 20

Office visits 15 Oral and maxillofacial surgery 26
Orthopedic devices 22 Out-of-pocket expenses 13
Outpatient facility care 29 Oxygen 29
Pap test 16 Physical examination 15
Physical therapy 20

Pre-admission testing 29 Precertification 17, 24
Preventive care, adult 16 Preventive care,
children 16, 17 Prescription drugs 36
Preventive services 16, 17 Prior approval 12
Prostate cancer screening 16 Prosthetic devices 22
Psychologist 34 Psychotherapy 35
Radiation therapy 19 Rehabilitation therapies 20
Renal dialysis 20 Room and board 12
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