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2001 Blue Choice
BlueChoice http:// www. bcbsra. com
2001
A Health Maintenance Organization

Serving: The New York counties of Monroe, Livingston, Wayne, Ontario,
Seneca and Yates.

Enrollment in this Plan is limited; see page 5 for requirements.

Enrollment codes for this Plan:
MK1 Self Only MK2 Self and Family

Independent Licensee of the BlueCross BlueShield Association
This Plan has Full accreditation from
the NCQA. See the 2001 Guide for
more information on NCQA.

For changes
in benefits
see page 7.

RI 73-510 1
1 Page 2 3
2001 Blue Choice 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 health care?..................................................................................................................... 5
Patients' Bill of Rights ................................................................................................................................. 5
Service Area................................................................................................................................................. 6
Section 2. How we change for 2001……………………………………….................................................................. 7
Program-wide changes................................................................................................................................. 7
Changes to this Plan..................................................................................................................................... 7
Section 3. How you get care …………... ..................................................................................................................... 8
Identification cards ...................................................................................................................................... 8
Where you get covered care......................................................................................................................... 8

Plan providers........................................................................................................................................ 8
Plan facilities ......................................................................................................................................... 8
What you must do to get covered care......................................................................................................... 8

Primary care .......................................................................................................................................... 8
Specialty care ........................................................................................................................................ 8
Hospital care.......................................................................................................................................... 9
Circumstances beyond our control............................................................................................................... 9
Services requiring our prior approval ........................................................................................................ 10
Section 4. Your costs for covered services ................................................................................................................. 11

Copayments ......................................................................................................................................... 11
Coinsurance ......................................................................................................................................... 11
Your out-of-pocket maximum ................................................................................................................... 11
Section 5. Benefits…………………………………………………………............................................................... 12
Overview.................................................................................................................................................... 12
(a) Medical services and supplies provided by physicians and other health care professionals ........... 13
(b) Surgical and anesthesia services provided by physicians and other health care professionals........ 21
(c) Services provided by a hospital or other facility, and ambulance services ..................................... 24
(d) Emergency services/ accidents......................................................................................................... 26
(e) Mental health and substance abuse benefits.................................................................................... 28
(f) Prescription drug benefits................................................................................................................ 30
(g) Special features ............................................................................................................................... 32
(h) Dental benefits ................................................................................................................................ 34
(i) Non-FEHB benefits available to Plan members.............................................................................. 35 2
2 Page 3 4
2001 Blue Choice 3 Table of Contents
Section 6. General exclusions --things we don't cover ............................................................................................. 36
Section 7. Filing a claim for covered services ............................................................................................................ 37
Section 8. The disputed claims process ...................................................................................................................... 38
Section 9. Coordinating benefits with other coverage ................................................................................................ 40

When you have…
Other health coverage ......................................................................................................................... 40
Original Medicare............................................................................................................................... 40
Medicare managed care plan .............................................................................................................. 42
TRICARE/ Workers Compensation/ Medicaid......................................................................................... 43
Other Government agencies.................................................................................................................... 43
When others are responsible for injuries................................................................................................. 43
Section 10. Definitions of terms we use in this brochure ........................................................................................... 44
Section 11. FEHB facts............................................................................................................................................... 45

Coverage information…
No pre-existing condition limitation.................................................................................................. 45
Where you get information about enrolling in the FEHB Program................................................... 45
Types of coverage available for you and your family........................................................................ 45
When benefits and premiums start..................................................................................................... 45
Your medical and claims records are confidential ............................................................................. 46
When you retire ................................................................................................................................ 46
When you lose benefits.............................................................................................................................. 46

When FEHB coverage ends............................................................................................................... 46
Spouse equity coverage .................................................................................................................... 46
Temporary Continuation of Coverage (TCC) ................................................................................... 46
Converting to individual coverage.................................................................................................... 47
Getting a Certificate of Group Health Plan Coverage ...................................................................... 47
Inspector General advisory ........................................................................................................................ 47
Index ....................................................................................................................................................................... 48
Summary of benefits.................................................................................................................................................... 49
Rates .......................................................................................................................................................................... 50 3
3 Page 4 5

2001 Blue Choice 4 Introduction/ Plain Language
Introduction
Blue Choice
165 Court Street
Rochester, NY 14647

This brochure describes the benefits of Blue Choice under our contract (CS 2506) 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 7. 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 Blue Choice.

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 Blue Choice 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.

Patients' Bill of Rights
Blue Choice, a health care plan of Blue Cross and Blue Shield of the Rochester Area is a Health Maintenance
Organization( HMO) that emphasizes comprehensive medical, surgical and preventive care through an IPA network of more
than 2,500 area physicians in private offices and a multi-specialty group practice at the Plan's four health centers.

Each member selects their own primary care doctor from within the private office option or from the medical center option.
Members of the same family can select different delivery systems. To be eligible for coverage, all services, except for
emergency care, must be provided, arranged, or authorized in advance by the member's primary care physician.

A women may see her Plan obstetrician/ gynecologist or certified nurse midwife directly with no need to be referred by her
primary care doctor. Routine exams are limited to two per year

Benefits for urgent care outside of this Plan's may be covered. This Plan is affiliated with HMO-USA, a network of BlueCross
and BlueShield HMOs that can coordinate your medical care. If you need more information, this Plan can tell you more about
its reciprocity benefits.

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 us, our
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.

Blue Cross Blue Shield of the Rochester area has been serving the Rochester community for over 60 years, with products such as Blue Choice, the area's largest health care plan.
Blue Choice is a Non-Profit organization
If you want more information about us, call 800/ 462-0108, or write to Blue Choice Member Services, 165 Court Street,
Rochester, NY 14647. You may also contact us by fax at 716/ 238-3659 or visit our website at www. bcbsra. com. 5
5 Page 6 7
2001 Blue Choice 6 Section 1
Service Area
To enroll in this Plan, you must live in or work in our Service Area. This is where our providers practice. Our service area is:
the New York Counties of Livingston, Monroe, Ontario, Seneca, Wayne and Yates.

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. However, you may also contact HMO-USA at 1-800-4-HMOUSA for urgent care and they will
set up an appointment with a doctor in the area where you are visiting or instruct you to go to the emergency room. We will
not pay for health care services that are not emergency care or authorized by HMO-USA.

If you or a covered family member move outside of our service area, you can enroll in another plan. If your dependents live
out of the area (for example, if your child goes to college in another state), you should consider enrolling in a fee-for-service
plan or an HMO that has agreements with affiliates in other areas. Guest Membership is available in most parts of the United
States from HMO-USA. Contact Blue Choice for more information regarding Guest Membership. 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. 6
6 Page 7 8

2001 Blue Choice 7 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 Blue Choice 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 higher patient cost sharing and
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 Blue Choice Member Services at (716) 454-4810, or checking our website www. bcbsra. com. 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 medications 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
Your share of the non-Postal premium will increase by 21. 1% for Self Only or 39. 0% for Self and Family. Diabetic supplies including blood glucose monitors, insulin pumps, insulin infusion devices, oral agents for controlling

blood sugar, and diabetes self-management education.
Hearing Aids, including exams, fitting, ear molds, replacements, repairs and maintenance not under warranty, for dependents up to age 18, not to exceed $600.00 every three years. 7
7 Page 8 9
2001 Blue Choice 8 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 us at
716/ 454-4810.

Where you get covered care You get care from "Plan providers" and "Plan facilities." You will only pay copayments, and/ or coinsurance and you will not have to file claims.

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 at www. bcbsra. com.

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 at
www. bcbsra. com..

What you must do to It depends on the type of care you need. First, you and each family get covered care 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. To
determine if a physician is a participating provider and accepting new patients,
you can refer to our Provider Directory or contact us at 716/ 454-4810.
.

Primary care Your primary care physician can be a family practitioner, internal medicine, pediatrician, general medicine or obstetrician/ gynecologist. Your primary care

physician will provide most of your health care, or give you a referral to see a
specialist.

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 see your eye doctor once every 24 months or an acupuncturist
without a referral.
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). 8
8 Page 9 10
2001 Blue Choice 9 Section 3
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 716/ 454-4810. If you are new to the
FEHB Program, we will arrange for you to receive care.

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. 9
9 Page 10 11
2001 Blue Choice 10 Section 3
Services requiring our Your primary care physician has authority to refer you for most services. prior approval 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-certification. Your physician must
obtain pre-certification for the following services:

1. Air Ambulance,
2. All Inpatient Admissions,
3. All Referrals to Non-Participating Providers,
4. Ambulatory Surgery,
5. Chemotherapy & Radiation Treatment,
6. Colonoscopy & Endoscopy Procedures,
7. Diabetic Equipment,
8. Home Health Care,
9. Home Infusion Therapy,
10. Inpatient Physical Rehabilitation,
11. Kidney Dialysis,
12. Magnetic Resonance Imaging (MRI) and Magnetic Resonance Angiography (MRA),
13. Mental Health Services,
14. Nutritional Counseling,
15. Organ & Bone Marrow Transplants,
16. Outpatient Alcohol or Drug Abuse,
17. Pain Management,
18. Short Term Therapy,
19. Skilled Nursing Facility Care, and
20. Sleep Apnea Studies. 10
10 Page 11 12
2001 Blue Choice 11 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 nothing.

Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care
Example: In our Plan, you pay 50% of our allowance for acupuncture services
and 20% for Prosthetic and Orthopedic Devices

Your out-of-pocket maximum We do not have an out-of-pocket maximum. 11
11 Page 12 13

2001 Blue Choice 12 Section 5
Section 5. Benefits --OVERVIEW
(See page 7 for how our benefits changed this year and page 49 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 (716) 454-4810 or at our website at www. bcbsra. com.

(a) Medical services and supplies provided by physicians and other health care professionals........................... 13-20
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
Alternative treatments Educational classes and programs

(b) Surgical and anesthesia services provided by physicians and other health care professionals....................... 21-23
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services..................................................... 24-25

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

(d) Emergency services/ accidents ........................................................................................................................ 26-27
Medical emergency Ambulance

(e) Mental health and substance abuse benefits ................................................................................................... 28-29
(f) Prescription drug benefits ..................................................................................................................................... 30
(g) Special features..................................................................................................................................................... 32
Dental benefits ............................................................................................................................................................. 34
(h) Non-FEHB benefits available to Plan members ................................................................................................... 35
Summary of benefits.................................................................................................................................................... 49 12
12 Page 13 14
2001 Blue Choice 13 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.
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
In physician'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

At home $10 per visit
Lab, X-ray and other diagnostic tests
Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Cat Scans/ MRI
Ultrasound
Electrocardiogram and EEG

Nothing 13
13 Page 14 15
2001 Blue Choice 14 Section 5( a)
Preventive care, adult
Routine screenings, such as:
Blood lead level – One annually
Total Blood Cholesterol – once every three years, ages 19 through 64
Colorectal Cancer Screening, including
Fecal occult blood test

Nothing

Sigmoidoscopy, screening – every five years starting at age 50 Nothing
Prostate Specific Antigen (PSA test) – one annually for men age 40 and older Nothing

Routine pap test Nothing
Annual Physical Exams Nothing
Allergy Injections Nothing
Vision Exams
The semi-annual exam may include physical exam of the eyes, refraction tests and assessment of binocular vision.
$10 per visit

Hearing Exams $10 per visit
Routine mammogram –covered 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

Nothing

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

Routine Immunizations, limited to:
Tetanus-diphtheria (Td) booster – once every 10 years, ages19 and over (except as provided for under Childhood immunizations)

Influenza/ Pneumococcal vaccines, annually, age 65 and over

$10 per visit

Preventive care, children You pay
Childhood immunizations recommended by the American Academy of pediatrics

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)

Nothing
$10 per visit

Nothing 14
14 Page 15 16
2001 Blue Choice 15 Section 5( a)
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; see page xx for other circumstances, such as extended stays for you or your baby.

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
Voluntary sterilization
Surgically implanted contraceptives
Injectable contraceptive drugs
Intrauterine devices (IUDs)

Nothing

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)

$10 per visit 15
15 Page 16 17
2001 Blue Choice 16 Section 5( a)
Infertility services continued You pay
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
Infertility drugs

All charges.

Allergy care
Testing and treatment
Allergy injection
$10 per visit

Nothing
Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy
desensitization
All charges.

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 23.

Respiratory and inhalation therapy
Inhalers are covered under pharmacy benefit, see page 30

Inhalation therapy equipment is covered under DME, see page 19
Dialysis – Hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic therapy

Growth hormone therapy (GHT)
Note: – We will only cover GHT when we preauthorize the treatment.
Call (716) 454-4810 for preauthorization. We will ask you to submit
information that establishes that the GHT is medically necessary. Ask
physician to have us authorize GHT before you begin treatment;
otherwise, we will only cover GHT services from the date you submit
the information. If you do not ask or if we determine GHT is not
medically necessary, we will not cover the GHT or related services and
supplies. See Services requiring our prior approval in Section 3.

$10 per visit 16
16 Page 17 18
2001 Blue Choice 17 Section 5( a)
Rehabilitative therapies You pay
Physical therapy, occupational therapy and speech therapy --
Up to two consecutive months per condition which in the judgement of the Plan's Medical Director can be expected to result in a

significant improvement through short term therapy
qualified physical therapists;
speech therapists; and
occupational therapists.
Note: We only cover therapy to restore bodily function or speech
when there has been a total or partial loss of bodily function or
functional speech due to illness or injury.

Cardiac rehabilitation following a heart transplant, bypass surgery, or any cardial infraction.

$10 per visit

Not covered:
long-term rehabilitative therapy
exercise programs

All charges.

Hearing services (testing, treatment, and supplies)
Hearing testing
Hearing Aids for children
Hearing testing for children through age 17 (see Preventive care, children)

$10 per visit
Balance after $600 every three years

Not covered:
hearing aids, testing and examinations for them
All charges.

Vision services (testing, treatment, and supplies) You pay
Semi annual exam (See Preventive Care) $10 per visit

One pair of eyeglasses or contact lenses to correct an impairment
directly caused by accidental ocular injury or intraocular surgery
(such as for cataracts)

$10 per visit

Eye exam to determine the need for vision correction for children through age 17 (see preventive care)
Annual eye refractions $60 toward the purchase of one pair of either prescription eyeglasses or
contact lenses once every 24 months. Prescription eyeglasses or contact
lenses covered annually for children to age 19.

$10 per visit

Not covered:
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

All charges. 17
17 Page 18 19
2001 Blue Choice 18 Section 5( a)
Foot care
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 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.

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.

$10 per visit

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 provided less than 3 years after the last one we covered

All charges. 18
18 Page 19 20
2001 Blue Choice 19 Section 5( a)
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;
walkers;
blood glucose monitors; and
insulin pumps.

Note: Call us at 716/ 454-4810 as soon as your Plan physician
prescribes this equipment. We will arrange with a health care provider
to rent or sell you durable medical equipment at discounted rates and
will tell you more about this service when you call.

$10 per visit

Not covered:
Motorized wheel chairs All charges.

Home health services
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 visit

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.

Alternative treatments
Chiropractic Services

Acupuncture – Up to 10 visits per calendar year
$10 per visit
50%

Not covered:
naturopathic services hypnotherapy

biofeedback

All charges. 19
19 Page 20 21
2001 Blue Choice 20 Section 5( a)
Educational classes and programs
Coverage is limited to:

Member Rewards includes:

Smoking Cessation
Nutrition counseling
First aid/ safety
Back care
Stress Management
General Wellness
Family Life

$5 per visit 20
20 Page 21 22
2001 Blue Choice 21 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
P O
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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.
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© for charges associated with the facility (i. e. hospital, surgical

center, etc.).

I M
P O
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A N
T

Benefit Description You pay
After the calendar year deductible…

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 prostethic devices. See 5( a) – Orthopedic braces and prosthetic devices for device coverage information.

$10 per office visit; nothing for
hospital visits

Surgical procedures continued on next page. 21
21 Page 22 23
2001 Blue Choice 22 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
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: We pay for internal breast prostheses as hospital benefits.
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.

See above.

Not covered:
Cosmetic surgery – 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
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;

$10 per visit 22
22 Page 23 24
2001 Blue Choice 23 Section 5( b)
Oral and maxillofacial surgery continued
Excision of leukoplakia or malignancies; 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.

$10 per visit

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

as the periodontal membrane, gingiva, and alveolar bone)

All charges.

Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single –Double
Pancreas
Allogeneic (donor) bone marrow transplants

Autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute

lymphocytic or non-lymphocytic leukemia; advanced Hodgkin's
lymphoma; advanced non-Hodgkin's lymphoma; advanced
neuroblastoma; breast cancer; multiple myeloma; epithelial ovarian
cancer; and testicular, mediastinal, retroperitoneal and ovarian germ
cell tumors

Limited Benefits -Treatment for breast cancer, multiple myeloma, and
epithelial ovarian cancer may be provided in an NCI-or NIH-approved
clinical trial at a Plan-designated center of excellence and if approved by
the Plan's medical director in accordance with the Plan's protocols.

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

Nothing

Anesthesia You pay
Professional services provided in –
Hospital (inpatient) Hospital outpatient department

Skilled nursing facility Ambulatory surgical center
Office

Nothing 23
23 Page 24 25
2001 Blue Choice 24 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
P O
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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.

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
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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.
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 (Note: calendar year
deductible applies.)

Nothing

Not covered:
Custodial 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. 24
24 Page 25 26
2001 Blue Choice 25 Section 5( c)
Outpatient hospital or ambulatory surgical center
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: – 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.

$10 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
Extended care benefit: The Plan provides a comprehensive range
of benefits with no dollar limit for 45 days per member per
calendar year when full-time skilled nursing care is necessary and
confinement in a skilled nursing facility is medically appropriate as
determined by a Plan doctor and approved by the Plan.

Nothing
.

Not covered: custodial care All charges
Hospice care
Supportive and palliative care for a terminally ill member is covered
in the home or hospice facility for up to 210 days. 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 stage of illness, with a life ecpectancy of
approximately six months or less.

Nothing

Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when medically appropriate Nothing 25
25 Page 26 27
2001 Blue Choice 26 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.

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
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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 – 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 doctor. In extreme emergencies, if you are unable to contact your doctor, contact the local emergency system (e. g., the 911 telephone
system) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan
member so they can notify the Plan. You or a family member must notify the Plan within 48 hours. It is your responsibility
to ensure that the Plan has been timely notified.

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

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

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

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

To be covered by this Plan, Any follow-up care recommended by non-Plan providers must be approved by the Plan or
provided by Plan providers.

If the emergency results in admission to a hospital, the emergency care copay is waived. 26
26 Page 27 28
2001 Blue Choice 27 Section 5( d)
Benefit Description You pay
Emergency within our service area

Emergency care at a doctor's office
Emergency care at an urgent care center
Emergency care as an outpatient or inpatient at a hospital, including doctor's services

$10 per visit

Emergency care as an outpatient or inpatient at a hospital, including
doctors' services
$50 per visit

Not covered: Elective care or non-emergency care All charges.
Emergency outside our service area

Emergency care at a doctor's office Emergency care at an urgent care center $10 per visit

Emergency care as an outpatient or inpatient at a hospital, including
doctors' services
$50 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
Professional ambulance service when medically appropriate.
Air Ambulance
See 5( c) for non-emergency service.

Nothing 27
27 Page 28 29
2001 Blue Choice 28 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
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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 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 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.
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
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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 visit

Diagnostic tests Nothing
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

Nothing

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. 28
28 Page 29 30
2001 Blue Choice 29 Section 5( e)
Preauthorization To be eligible to receive these benefits you must follow your treatment plan and all the following authorization processes:
The Pre-authorization procedure must be followed regardless whether the Member is
within The Plan's Service Area or not. Pre-authorization need not be obtained for Emergency care. In making the determination to issue Pre-authorization The Plan

will examine the circumstances surrounding the Member's condition and the care provided; including reasons for providing or prescribing the care; and any unusual
circumstances. However, the fact that the Member's Doctor prescribed the care does not automatically mean that the care qualifies for The Plan's payments under
this Certificate. The provider, prior to recommending or ordering any pre-authorized services, must call Blue Choice at (716) 454-4591. For obtaining provider directories,
call Member Service Department at (716) 454-4810.

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 conditions:

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 these conditions apply to you, we will allow you reasonable time to transfer your
care to a network 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. The
transitional period will last for up to 90 days from the date you receive notice of the
change. You may receive this notice prior to January 1, 2001, and the 90 day
period begins with receipt of the notice.

Network limitation We may limit your benefits if you do not follow your treatment plan.

How to submit network claims Claims are submitted by your provider. 29
29 Page 30 31
2001 Blue Choice 30 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.
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 physician must write the prescription – or – A plan physician or licensed dentist must write the prescription.

Where you can obtain them. You may fill the prescription at a participation pharmacy, a non-participating pharmacy, or by mail.
Non participating pharmacy – If you use a non-participating pharmacy you must submit a claim to us for the Prescription Drug. Our payment will be made directly to you, and will be limited to the Allowed
Amount less Copayment and Ancillary Charge. You will not be reimbursed for the difference between our
Allowed Amount and the Non-Participating Pharmacy's charge for the Prescription Drug when the charge
exceeds our Allowed Amount.

These are the dispensing limitations. Retail – Prescription drugs are dispensed for up to a 34-day supply when referred by a Plan doctor and filled at a participating pharmacy.

Mail Order – Maintenance drugs are availible through mail order for up to a 90 day when ordered by a Plan
doctor and obtained through our mail order program with Express Scripts.

When generic substitution is permissible, (i. e., a generic is available and the prescribing doctor does not
require the use of a brand name drug), but you request the name brand drug, You pay the $8 copay for
prescription drugs at a Plan pharmacy or the $7 copay for maintenance drugs by mail plus the price
difference between the generic and the name brnd drug.

When you have to file a claim. You will have no claims to file unless you use a non-participating
pharmacy..

Prescription drug benefits begin on the next page. 30
30 Page 31 32
2001 Blue Choice 31 Section 5( f)
Benefit Description You pay After the calendar year deductible…
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan
physician and obtained from a Plan pharmacy or through our mail order
program:

Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase, except as excluded

below.
Insulin Disposable needles and syringes for the administration of covered

medications
Diabetic supplies including blood glucose monitors, insulin pumps, insulin infusion devices, oral agents for controlling blood sugar, and

diabetes self-management education.

Drugs for sexual dysfunction (see Prior authorization below) Contraceptive drugs and devices

Note: If there is no generic equivalent available, you will still have to pay
the brand name copay.

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.

We have an open formulary. If your physician believes a name brand product is necessary or there is no generic available, your
physician may prescribe a name brand drug from a formulary list.
This list of name brand drugs is a preferred list of drugs that we
selected to meet patient needs at a lower cost. To order a
prescription drug brochure, call (716) 454-4810.

Retail
$8 copay per 34 day supply….
Mail Order
$2 copay generic per 30 day
supply

$7 copay brand name per 30 day
supply

Not covered:
Drugs and supplies for cosmetic purposes
Vitamins, nutrients and food supplements even if a physician prescribes or administers them

Nonprescription medicines
Drugs to enhance athletic performance Implanted time-release medications other than Norplant

Drugs for weight loss

All Charges 31
31 Page 32 33
2001 Blue Choice 32 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.

Reciprocity benefit HMOBlue USA
Away from Home Care & Guest Membership
From BlueCross BlueShield of the Rochester Area

Enjoy the comforts of your HMO wherever you go.
Now the benefits you enjoy from your HMO at home, are with you where
ever you happen to be. Away From Home Care coverage puts you in touch
with HMO health care from qualified physicians in nearly every state across
the country, wherever you need it. You'll receive the same health care
coverage you enjoy at home, through the country's largest HMO network,
HMO Blue USA. The benefits of Away From Home Care coverage are
yours automatically – and at no extra cost – when you join our HMO.

The HMO that stays with you whenever you're away from home. Should you ever come down with an unexpected illness or injury while
traveling, which can't wait to be treated at home, you can rest assured
knowing that you have a place to turn. We call it Urgent Care, because it
delivers just that: the help you need, whenever you need it.

No paperwork whatsoever. You're not feeling well to begin with. The last thing you need is a big
expense to make things worse. With Away From Home Care, you can take
comfort knowing you'll have no claims to file, no paperwork and no
payment at the time of service. 32
32 Page 33 34
2001 Blue Choice 33 Section 5( g)
Reciprocity benefit continued Far-reaching comforts no other HMO provides. HMOBlue USA offers health care coverage in more than 200 major cities
across the country. It's also reassuring to know HMOBlue USA's Away
From Home Care program is sponsored by the BlueCross and BlueShield
Association.

You know how important the right HMO coverage is when you're at home.
Choose Blue Choice from BlueCross and BlueShield of the Rochester Area
and keep the benefits of your local coverage wherever you go.

Even your follow-ups follow you. Should your travel schedule require that you miss a scheduled follow-up
appointment at home, our Follow-Up Care lets you conveniently schedule
an appointment for ongoing care near your travel destination. Like every
Away From Home Care service, you'll receive the same quality you enjoy at
home.

Centers of excellence for transplants/ heart surgery/ etc BlueCross BlueShield of the Rochester Area works with other
BlueCross plans to identify centers of excellence which offer quality
care in specialized areas. When necessary the plan's Medical
Director will recommend, members with diseases and conditions that
can not be handled by our providers, to be sent to centers of
excellence. 33
33 Page 34 35
2001 Blue Choice 34 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
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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.

We cover hospitalization for dental procedures only when a nondental physical impairment exists which makes hospitalization 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
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A N
T

Accidental injury benefit You pay
We cover restorative services and supplies necessary to promptly repair (but
not replace) sound natural teeth. The need for these services must result from
an accidental injury.

$10 copay per office visit

Dental benefits
We have no other dental benefits. 34
34 Page 35 36
2001 Blue Choice 35 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.

Member Rewards has been developed by Blue Choice to introduce you to selected local resources that will help you get into
shape, have more energy, deal more effectively with life's problems and increase your chances of preventing heart disease,
cancer or stroke. Take advantage of the health and wellness programs offered to Blue Choice members.

Private office option Member Rewards offers most health and wellness programs for just $5 a session. Topics include nutrition,
smoking cessation, first aid/ safety, back care, stress management, general wellness and family life.

Choice discounts Member Rewards offers Choice Discounts that provide savings on health and fitness club membership,
exercise programs, and sports equipment, ranging from footwear to cardiovascular exercise machines. To obtain a list of
Member Rewards and Choice Discounts, call 716/ 454-4810.

To further promote wellness and preventive care, members may enroll in health education programs at the health centers. These
programs are professionally led courses on nutrition, back care, smoking cessation, stress management and many other topics.
Most programs cost just $5. 35
35 Page 36 37
2001 Blue Choice 36 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 or when the pregnancy is the result of an act of rape or incest ;

Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program. 36
36 Page 37 38
2001 Blue Choice 37 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 (716) 454-4810.
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: Blue Choice
165 Court Street Rochester, NY 14647

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. 37
37 Page 38 39
2001 Blue Choice 38 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 – including a request for preauthorization:

Step Description

1 Ask us in writing to reconsider our initial decision. Write to us at: 165 Court Street, Rochester NY, 14647. You must:
(a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: 165 Court Street, Rochester NY, 14647; 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
request— 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 3, 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. 38
38 Page 39 40
2001 Blue Choice 39 Section 8
The Disputed Claim process continued
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
(716) 454-4810 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 3 at 202/ 606-0737 between 8 a. m. and 5 p. m. eastern time. 39
39 Page 40 41
2001 Blue Choice 40 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. Your care must continue to be
authorized by your Plan PCP.

(Primary payer chart begins on next page.) 40
40 Page 41 42
2001 Blue Choice 41 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 is… A. When either you --or your covered spouse --are age 65 or over and …

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

2) Are an annuitant,
3) Are a reemployed annuitant with the Federal government when…
a) The position is excluded from FEHB, or ……………….…………… ………..

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

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, (for Part B
services)


(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,


(except for claims
related to Workers'
Compensation.)

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

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

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

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

C. When you or a covered family member have FEHB and…
1) Are eligible for Medicare based on disability, and
a) Are an annuitant, or………………………………………………… ……….

b) Are an active employee ……………….……………….…………… …………………….. ……. 41
41 Page 42 43

2001 Blue Choice 42 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
(716) 454-4810 or on the web at: www. bcbsra. com.

We waive some costs when you have Medicare --When Medicare is the primary payer, we will waive some out-of-pocket costs, as follows:

Medical services and supplies provided by physicians and other health care
professionals.

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/ 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 Managed
Care Plan 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. 42
42 Page 43 44
2001 Blue Choice 43 Section 9
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.

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.

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. 43
43 Page 44 45
2001 Blue Choice 44 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 11.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 11.

Covered services Care we provide benefits for, as described in this brochure.
Experimental or Blue Choice uses published peer-reviewed medical literature about the efficiency
Investigational and improvement outcomes of technology, along with the United States Food and Drug Administration approval for marketing of medical devices, drugs or

biologicals for a particular diagnosis or condition.

Medical necessity Medically Necessary Care is care which, according to The Plan's criteria is: (a) Consistent with the symptoms or diagnosis and treatment of the Member's condition,
disease, ailment or injury, (b) in accordance with standards of acceptable medical
practice, (c) not solely for the Member's convenience, or that of the Member's Doctor
or other Provider, (d) the most appropriate supply, place of service, or level of service
which can safely be provided to the Member, (e) provided for the diagnosis or the direct
care and treatment of the Member's condition, illness, disease or injury, and (f) when
applied to hospitalization, the Member requires acute care as a bed patient due to the
nature of the services rendered, or the Member's condition, and the Member could not
have received safe or adequate care in any other setting (e. g. as an outpatient).

Us/ We Us and we refer to Blue Choice

You You refers to the enrollee and each covered family member. 44
44 Page 45 46
2001 Blue Choice 45 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.

When benefits and The benefits in this brochure are effective on January 1. If you are new to premiums start 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. 45
45 Page 46 47
2001 Blue Choice 46 Section 11
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 Eligibility 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. 46
46 Page 47 48
2001 Blue Choice 47 Section 11
Converting to You may convert to a 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 (716) 454-4810 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. 47
47 Page 48 49
2001 Blue Choice 48 Index
Index
Do not rely on this page; it is for your convenience and does not explain your benefit coverage.

Accidental injury 26 Allergy tests 14
Alternative treatment 19
Ambulance 27
Anesthesia 24
Autologous bone marrow transplant 23
Biopsies 21 Blood and blood plasma 24

Breast cancer screening 14
Changes for 2001 7 Chemotherapy 16

Childbirth 15
Cholesterol tests 14
Claims 37
Coinsurance 11
Colorectal cancer screening 14
Contraceptive devices and drugs 15
Coordination of benefits 40
Covered providers 8
Deductible 11 Definitions 44

Dental care 34
Diagnostic services 13
Disputed claims review 38
Donor expenses (transplants) 23
Durable medical equipment (DME) 19
Educational classes and programs 20 Effective date of enrollment 45

Emergency 26
Experimental or investigational 36
Eyeglasses 17
Family planning 15 Fecal occult blood test 14

General Exclusions 36 Hearing services 17

Home health services 19
Hospice care 25
Home nursing care 25
Hospital 25
Immunizations 24 Infertility 14

Inhospital physician care 21
Inpatient Hospital Benefits 21
Insulin 31
Laboratory and pathological services 13

Magnetic Resonance Imagings
(MRIs) 13
Mail Order Prescription Drugs 31
Mammograms 14
Maternity Benefits 15
Medicaid 43
Medically necessary 9
Medicare 40
Mental Conditions/ Substance
Abuse Benefits 28
Newborn care 15 Non-FEHB Benefits 35

Nursery charges 15
Obstetrical care 15 Occupational therapy 17

Office visits 13
Oral and maxillofacial surgery 22
Orthopedic devices 18
Outpatient facility care 25
Oxygen 25
Pap test 14 Physical examination 14

Physical therapy 17
Physician 13

Pre-admission testing 25
Precertification 10
Preventive care, adult 14
Preventive care, children 14
Prescription drugs 30
Preventive services 14
Prostate cancer screening 14
Prosthetic devices 18
Psychologist 28
Psychotherapy 28
Radiation therapy 16 Rehabilitation therapies 17

Renal dialysis 16
Room and board 24
Skilled nursing facility care 25 Smoking cessation 35

Speech therapy 17
Sterilization procedures 15
Substance abuse 28
Surgery 21
Anesthesia 21 Outpatient 21

Reconstructive 22 Syringes 31
Temporary continuation of coverage 46
Transplants 23
Treatment therapies 16
Vision services 17 Well child care 14

Wheelchairs 19
Workers' compensation 43
X-rays 13 48
48 Page 49 50
2001 Blue Choice 49
Summary of benefits for the Blue Choice -2001
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the definitions,
limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover; for more detail,
look inside.

If you want to enroll or change your enrollment in this Plan, be sure to put the correct enrollment code from the
cover on your enrollment form.

We only cover services provided or arranged by Plan physicians, except in emergencies.

Benefits You Pay Page
Medical services provided by physicians:
Diagnostic and treatment services provided in the office................. Office visit copay: $10 primary care; $10 specialist 13

Services provided by a hospital:
Inpatient ...........................................................................................

Outpatient.........................................................................................

Nothing
$10 copay
24
25

Emergency benefits:
In-area .............................................................................................
Out-of-area ......................................................................................

$50 per… visit.

$50 per…

26
27

Mental health and substance abuse treatment ..................................... Regular cost sharing. 28
Prescription drugs................................................................................. Drugs prescribed by a Plan doctor
and obtained at a Plan pharmacy.
You pay a $8 copay per
prescription unit or refill. For
maintenance drugs purchased by
mail, you pay $2 (generic) or $7
(name brand) per 30-day supply
for up to a 90-day supply

30

Dental Care....................................................................................... No benefit. 34
Vision Care....................................................................................... One refraction and $60 toward
eyeglasses or contact lenses every 24 months under age 19 annually.

You pay a $10 copay per visit

17

Special features: Member Rewards – Health and wellness programs and discounts. 35
Protection against catastrophic costs ...............................................
(your out-of-pocket maximum) Your out-of-pocket expenses for benefits covered under this Plan
are limited to the stated
copayments which are required for
a few benefits

11 49
49 Page 50
2001 Blue Choice 50
2001 Rate Information for
Blue Choice

Non-Postal rates apply to most non-Postal enrollees. If you are in a special enrollment category, refer to
the FEHB Guide for that category or contact the agency that maintains your health benefits enrollment.

Postal rates apply to career Postal Service employees. Most employees should refer to the FEHB Guide
for United States Postal Service Employees, RI 70-2. Different postal rates apply and special FEHB guides
are published for Postal Service Nurses and Tool & Die employees (see RI 70-2B); and for Postal Service
Inspectors and Office of Inspector General (OIG) employees (see RI 70-2IN).

Postal rates do not apply to non-career postal employees, postal retirees, or associate members of any postal
employee organization. Refer to the applicable FEHB Guide.

Non-Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type of
Enrollment Code
Gov't
Share
Your
Share
Gov't
Share
Your
Share
USPS
Share
Your
Share

Self Only MK1 $82.01 $27.34 $177.70 $59.23 $97.05 $12.30
Self and Family MK2 $195.82 $77.86 $424.28 $168.69 $231.17 $42.51 50

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