Pages 1--60 from Carelink Health Plans

For changes in benefits,
see page 8.

Serving: State of West Virginia
Enrollment in this Plan is limited; see page 5 for requirements.

Enrollment codes for this Plan:
4C1 Self Only 4C2 Self and Family

Special Notice: Health Assurance and Carelink have merged. Health Assurance enrollees will automatically be transferred to Carelink unless they
make a change to a different plan during open season. Please read this brochure carefully for benefit changes.

RI 73-676 1
1 Page 2 3
2001 Carelink Health Plans Table of Contents 2
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 ................................................................................................................................. 6
Service Area................................................................................................................................................. 7
Section 2. How we change for 2001……………………………………….................................................................. 8
Program-wide changes................................................................................................................................. 8
Changes to this Plan..................................................................................................................................... 8
Section 3. How you get care …………... ..................................................................................................................... 9
Identification cards....................................................................................................................................... 9
Where you get covered care......................................................................................................................... 9
Plan providers........................................................................................................................................ 9
Plan facilities ......................................................................................................................................... 9
What you must do to get covered care ......................................................................................................... 9
Primary care........................................................................................................................................... 9
Specialty care......................................................................................................................................... 9
Hospital care ........................................................................................................................................ 10
Circumstances beyond our control............................................................................................................. 11
Services requiring our prior approval ........................................................................................................ 11
Section 4. Your costs for covered services ................................................................................................................. 12
Copayments ......................................................................................................................................... 12
Coinsurance ......................................................................................................................................... 12
Your out-of-pocket maximum.................................................................................................................... 12
Section 5. Benefits…………………………………………………………............................................................... 13
Overview.................................................................................................................................................... 13
(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........ 24
(c) Services provided by a hospital or other facility, and ambulance services...................................... 29
(d) Emergency services/ accidents ......................................................................................................... 32
(e) Mental health and substance abuse benefits .................................................................................... 34
(f) Prescription drug benefits................................................................................................................ 36
(g) Special features ............................................................................................................................... 40
(h) Dental benefits................................................................................................................................. 41
(i) Non-FEHB benefits available to Plan members.............................................................................. 42 2
2 Page 3 4
2001 Carelink Health Plans Table of Contents 3
Section 6. General exclusions --things we don't cover............................................................................................. 43
Section 7. Filing a claim for covered services............................................................................................................ 44
Section 8. The disputed claims process...................................................................................................................... 45
Section 9. Coordinating benefits with other coverage................................................................................................ 47
When you have…
Other health coverage ...................................................................................................................... 47
Original Medicare ............................................................................................................................ 47
Medicare managed care plan............................................................................................................ 49
TRICARE/ Workers' Compensation/ Medicaid ....................................................................................... 49
Other Government agencies ................................................................................................................... 51
When others are responsible for injuries ................................................................................................ 51
Section 10. Definitions of terms we use in this brochure........................................................................................... 52
Section 11. FEHB facts.............................................................................................................................................. 53

Coverage information................................................................................................................................
No pre-existing condition limitation ............................................................................................. 53
Where you get information about enrolling in the FEHB Program............................................... 53
Types of coverage available for you and your family................................................................... 53
When benefits and premiums start ................................................................................................ 54
Your medical and claims records are confidential ........................................................................ 54
When you retire............................................................................................................................ 54
When you lose benefits ....................................................................................................................... 54
When FEHB coverage ends .......................................................................................................... 54
Spouse equity coverage................................................................................................................ 54
Temporary Continuation of Coverage (TCC) .............................................................................. 54
Enrolling in TCC........................................................................................................................... 54
Converting to individual coverage ............................................................................................... 55
Getting a Certificate of Group Health Plan Coverage.................................................................. 55
Inspector General Advisory ......................................................................................................... 55

Index ............................................................................................................................................................... 56
Summary of benefits ................................................................................................................................................... 58
Rates………………………………………………………………………………………………………….. Back cover 3
3 Page 4 5
2001 Carelink Health Plans 4 Introduction/ Plain Language
Introduction
Carelink Health Plans 141 Summers Square
Charleston, WV 25326
This brochure describes the benefits of Carelink Health Plans under our contract (CS2734) 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 8. 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 Carelink Health Plans.

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 Carelink Health Plans 5 Section 1
Section 1. Facts about this HMO plan
This Plan is a health maintenance organization (HMO). We require you to see specific physicians, hospitals, and other providers that contract with us. These Plan providers coordinate your health care services.

HMOs emphasize preventive care such as routine office visits, physical exams, well-baby care, and immunizations, in addition to treatment for illness and injury. Our providers follow generally accepted medical practice when
prescribing any course of treatment.
When you receive services from Plan providers, you will not have to submit claim forms or pay bills. You only pay the copayments, coinsurance, and deductibles described in this brochure. When you receive emergency services from
non-Plan providers, you may have to submit claim forms.
You should join an HMO because you prefer the plan's benefits, not because a particular provider is available. You cannot change plans because a provider leaves our Plan. We cannot guarantee that any one physician,
hospital, or other provider will be available and/ or remain under contract with us.
How we pay providers
We contract with individual physicians, medical groups, and hospitals to provide the benefits in this brochure. These Plan providers accept a negotiated payment from us, and you will only be responsible for your copayments or
coinsurance.

Who provides my health care?
Carelink Health Plans of Charleston, West Virginia is an individual practice prepayment plan that allows you to choose a personal family doctor, otherwise known as a primary care physician, from a list of over 1380 physicians. If
specialty services are necessary, the primary care physician will refer you to an appropriate Plan doctor.
When you join Carelink Health Plans, you and each family member individually choose a primary care physician from among internists, obstetrician/ gynecologists, pediatricians, general practitioners, and family practice physicians,
and in some areas, urgent care centers.
The first and most important decision each member must make is the selection of a primary care doctor. The decision is important since it is through this doctor that all other health services, particularly those of specialists, are obtained.
It is the responsibility of your primary care doctor to obtain any necessary authorizations from the Plan before referring you to a specialist or making arrangements for hospitalization. Services of other providers are covered only
when you have been referred by your primary care doctor with the following exceptions: a woman may see her plan gynecologist for her annual routine examination or for maternity care without a referral.

The Plan's provider directory lists primary care doctors (family practitioners, general practitioners, pediatricians, and internists) with their locations and phone numbers, and notes whether or not the doctor is accepting new patients.
Directories are updated on a regular basis and are available at the time of enrollment or upon request by calling the Member Services Department at 1-800-348-2922; you can also find out if your doctor participates with this Plan by
calling this number. If you are interested in receiving care from a specific provider who is listed in this directory, call the provider to verify that he or she still participates with the Plan and is accepting new patients. Important note:
When you enroll in this Plan, services (except for emergency benefits) are provided through the Plan's delivery system; the continued availability and/ or participation of any one doctor, hospital, or other provider, cannot be
guaranteed.
If you enroll, you will be asked to let the Plan know which primary care doctor( s) you've selected for you and each member of your family by sending a selection form to the Plan or calling Customer Service at 1-800-348-2922. If you
need help choosing a doctor, call the Plan. Members may change their doctor selection anytime by notifying the Plan 30 days in advance. 5
5 Page 6 7
2001 Carelink Health Plans 6 Section 1
If you are receiving services from a doctor who leaves the Plan, the Plan will pay for covered services until the Plan can arrange with you for you to be seen by another participating doctor.
Patients' Bill of Rights
OPM requires that all FEHB Plans comply with the Patients' Bill of Rights recommended by the President's Advisory Commission on Consumer Protection and Quality in the Health Care Industry. You may get information about 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.

Carelink Health Plans complies with all State of West Virginia licensing requirements Disenrollment rates
Years in existence Carelink Health Plans meets State, Federal and accreditation requirements for fiscal solvency, confidentiality and
transfer of medical records
If you want more information about us, call 1-800-348-2922, or write to Carelink Health Plans, 141 Summers Square, Charleston, WV 25326. You may also contact us by fax at 724/ 778-4299 or visit our website at www. cvty. com. 6
6 Page 7 8
2001 Carelink Health Plans 7 Section 1
Service Area
To enroll with Carelink, you must live or work in our service area. This is where our providers practice. Carelink's service area includes all 55 counties in the State of West Virginia.

Ordinarily, you must get your care from providers who contract with us. If you receive care outside our service area, we will pay only for emergency care. We will not pay for any other health care services rendered outside of the plan
unless it is an emergency or the services have been authorized by our medical director.
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), he/ she has coverage for
emergency services only from non-plan providers. 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. 7
7 Page 8 9
2001 Carelink Health Plans 8 Section 3
Section 2. How we change for 2001
Program-wide changes
The plain language team reorganized the brochure and the way we describe our benefits. We hope this will make it easier for you to compare plans.

This year, the Federal Employees Health Benefits Program is implementing network mental health and substance abuse parity. This means that your coverage for mental health, substance abuse, medical, surgical, and hospital
services from providers in our plan network will be the same with regard to coinsurance, copays, and day and visit limitations when you follow a treatment plan that we approve. Previously, we placed higher patient cost
sharing and 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 Customer Service at 1-800-348-2922, or checking our website at www. carelink. cvty. 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 the medicines you take.
Make sure you get the results of any test or procedure.
Talk with your doctor and health care team about your options if you need hospital care.
Make sure you understand what will happen if you need surgery.
We clarified the language to show that anyone who needs a mastectomy may choose to have the procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure. Previously, the

language referenced only women.

Changes to this Plan
Your share of the non-Postal premium will increase by 32. 2% for Self Only or 89. 0% for Self and Family.
Carelink Health Plans' service area for January 2000 included 26 counties in the State of West Virginia. Our service area has now been expanded to all 55 West Virginia counties.

Health Assurance and Carelink have merged. Health Assurance enrollees will automatically be transferred to Carelink unless they make a change to a different plan during open season. Please read this brochure carefully for
benefit changes. Specialist Physician Office Visits are now covered with a $20 member copayment.
Outpatient Surgery performed at a surgical center or hospital is now covered with a $100 member copayment.
Allergy Testing and Care visit (including serum) is now covered with a $20 member copayment. Annual Copayment Maximums are now $1500 for single family members or $3000 per family.
Durable Medical Equipment is now covered with a 40% member copayment. Diagnosis and Treatment of Infertility is now covered with a 40% member copayment.
Inpatient and Outpatient Hospital stays are now covered with a $100 member copayment per admission. Urgent Care Visits are covered with a $30 member copayment. 8
8 Page 9 10
2001 Carelink Health Plans 9 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 1-800-
348-2922.

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. You can also verify that a provider participates with us by
calling 1-800-348-2922.
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. You can also verify that a facility participates with us by calling 1-800-348-2922.

What you must do to get It depends on the type of care you need. First, you and each family 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. Please notify us of your choice of your primary
care physician by calling Customer Service at 1-800-348-2922.

Primary care Your primary care physician can be among internists, obstetrician/ gynecologists, pediatricians, general practitioners, and
family practice physicians, and in some areas, urgent care centers. .
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, female members can see their participating gynecologist one
time per year for their annual gynecological exam 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 9
9 Page 10 11
2001 Carelink Health Plans 10 Section 3
a certain number of visits without additional referrals. Your primary care physician will use our criteria when creating your treatment plan
(the physician may have to get an authorization or approval beforehand).

If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide
what treatment you need. If he or she decides to refer you to a specialist, ask if you can see your current specialist. If your current
specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see
a specialist who does not participate with our Plan.
If you are seeing a specialist and your specialist leaves the Plan, call your primary care physician, who will arrange for you to see another
specialist. You may receive services from your current specialist until we can make arrangements for you to see someone else.

If you have a chronic or disabling condition and lose access to your specialist because we:
terminate our contract with your specialist for other than cause; or
drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan; or

reduce our service area and you enroll in another FEHB Plan,
you may be able to continue seeing your specialist for up to 90 days after you receive notice of the change. Contact us, or, if we drop out
of the program, contact your new plan.
If you are in the second or third trimester of pregnancy and you lose access to your specialist based on the above circumstances, you can
continue to see your specialist until the end of your postpartum care, even if it is beyond the 90 days.

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission
to a skilled nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 1-800-348-2922. 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. 10
10 Page 11 12
2001 Carelink Health Plans 11 Section 3
Circumstances beyond our control Under certain extraordinary circumstances, such as natural disasters, we may have to delay your services or we may be unable to provide them.
In that case, we will make all reasonable efforts to provide you with the necessary care.

Services requiring our prior approval Your primary care physician has authority to refer you for most services.
For certain services, however, your physician must obtain approval from us. Before giving approval, we consider if the service is covered,
medically necessary, and follows generally accepted medical practice.
We call this review and approval process precertification. Your plan physician is responsible for obtaining all necessary precertifications
including, but not limited to:
Inpatient Admissions Outpatient Surgeries
Transplants Orthotics
Durable Medical Equipment Out-of-Network Services
MRI/ CAT Scans 11
11 Page 12 13
2001 Carelink Health Plans 12 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider when you receive services.

Example: When you see your primary care physician you pay a copayment of $10 per office visit and when you go in the hospital, you
pay $100 per admission.
Coinsurance Coinsurance is the percentage of our negotiated fee that you must pay for your care.

Example: In our Plan, you pay 40% of our allowance for infertility services and durable medical equipment.

Your out-of-pocket maximum After your copayments and coinsurance total $1500 per person or $3000 per family enrollment in any calendar year, you do not have to pay any
more for covered services. However, copayments and coinsurance for the following services do not count toward your out-of-pocket maximum,
and you must continue to pay copayments and coinsurance for these services:

Infertility Services Prescription Drugs
Family Planning Procedure
Be sure to keep accurate records of your copayments and coinsurance since you are responsible for informing us when you reach the maximum. 12
12 Page 13 14
2001 Carelink Health Plans 13 Section 5
Section 5. Benefits --OVERVIEW (See page 8 for how our benefits changed this year and page 58 for a benefits summary.)
NOTE: This benefits section is divided into subsections. Please read the important things you should keep in mind at the beginning of each subsection. Also read the General Exclusions in Section 6; they apply to the benefits in the
following subsections. To obtain claims forms, claims filing advice, or more information about our benefits, contact us at 1-800-348-2922 or at our website at www. carelink. cvty. com.
(a) Medical services and supplies provided by physicians and other health care professionals...................................... 14-23
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests
Preventive care, adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies Rehabilitative therapies

Hearing services (testing, treatment, and supplies)
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 ....................... 24-28
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services ..................................................... 29-31
Inpatient hospital Outpatient hospital or ambulatory surgical
center
Extended care benefits/ skilled nursing care facility benefits
Hospice care Ambulance

(d) Emergency services/ accidents ................................................................................................................. 32-33 Medical emergency Ambulance
(e) Mental health and substance abuse benefits ............................................................................................ 34-35
(f) Prescription drug benefits ............................................................................................................................... 36-39
(g) Special features .................................................................................................................................................... 40

(h) Dental benefits ..................................................................................................................................................... 41
(i) Non-FEHB benefits available to Plan members .................................................................................................. 42

Summary of benefits ................................................................................................................................................... 58 13
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2001 Carelink Health Plans 14 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

$10per office visittoyourprimary carephysician

$20peroffice visittoaspecialist
Professional services of physicians
In an urgent care center
$30 per office visit

Professional services of physicians
During a hospital stay
Nothing

Professional services of physicians
In a skilled nursing facility
20% copayment

Professional services of physicians
Initial examination of a newborn child covered under a family enrollment
Nothing during initial hospital stay

Professional services of physicians
Office medical consultations

$10perofficevisit toyourprimarycare physician

$20peroffice visittoaspecialist
Professional services of physicians
Second surgical opinion
$20 per office visit

Professional services of physicians
At home

$10perofficevisit toyourprimarycare physician

$20peroffice visittoaspecialist

Diagnostic and treatment services --Continued on next page 14
14 Page 15 16
2001 Carelink Health Plans 15 Section 5( a)
Diagnostic and treatment services (Continued) You pay
Lab, X-ray and other diagnostic tests

Tests, such as:
Blood tests
Urinalysis
Non-routine pap tests
Pathology
X-rays
Non-routine Mammograms
Ultrasound
Electrocardiogram and EEG
CAT Scans
MRI

Nothing

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

$10 per office visit to your primary care physician
$20 per office visit to a specialist

Sigmoidoscopy, screening – every five years starting at age 50 $10 per office visit to your primary care physician
$20 per office visit to a specialist
Prostate Specific Antigen (PSA test) – one annually for men age 40 and older $10 per office visit to your primary care physician

$20 per office visit to a specialist
Routine pap test
Note: The office visit is covered if pap test is received on the same day; see Diagnosis and Treatment, above.

$10 per office visit to your primary care physician

$20 per office visit to a specialist 15
15 Page 16 17
2001 Carelink Health Plans 16 Section 5( a)
Preventive care, adult (Continued) You pay
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

$10 per office visit to your primary care physician
$20 per office visit to a specialist

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 office visit to your primary care physician
$20 per office visit to a specialist

Preventive care, children You pay
Childhood immunizations recommended by the American Academy of Pediatrics $10 per office visit to your primary care physician

$20 per office visit to a specialist
Examinations, such as:
Eye exams through age 17 to determine the need for vision correction.

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

$10 per office visit to your primary care physician
$20 per office visit to a specialist 16
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2001 Carelink Health Plans 17 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 29 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).

$20 for the initial office visit to diagnose the pregnancy;
copayments for all prenatal and postnatal care office visits are
waived after the initial visit.
$100 copay for the hospital admission for the delivery

Not covered: Routine sonograms to determine fetal age, size or sex All charges
Family planning
Voluntary sterilization including vasectomy and tubal ligation Nothing

Not covered: reversal of voluntary surgical sterilization, genetic counseling, surgically implanted contraceptives, injectable
contraceptive drugs, intrauterine devices (IUDs)
All charges.

Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial insemination:
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)

40% member copayment 17
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2001 Carelink Health Plans 18 Section 5( a)
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
Fertility Drugs

All charges.

Allergy care
Testing and treatment
Allergy injection
$20 per office visit

Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy desensitization All charges. 18
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2001 Carelink Health Plans 19 Section 5( a)
Treatment therapies You pay
Chemotherapy and radiation therapy
Note: High dose chemotherapy in association with autologous bone marrow transplants are limited to those transplants listed under

Organ/ Tissue Transplants on page 27.
Respiratory and inhalation therapy
Dialysis – Hemodialysis and peritoneal dialysis
Intravenous (IV)/ Infusion Therapy – Home IV and antibiotic therapy

Growth hormone therapy (GHT)
Note: Plan physicians are responsible for obtaining all applicable precertifications.

$20 per office visit 19
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2001 Carelink Health Plans 20 Section 5( a)
Rehabilitative therapies You pay
Physical therapy, occupational therapy and speech therapy --
60 visits per course of treatment for the services of each of the following:

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 a myocardial infarction, is provided for up to 36 sessions

$20 per office visit

Not covered:
Long-term rehabilitative therapy
exercise programs

All charges.

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

Not covered: all other hearing testing
hearing aids, testing and examinations for them
All charges. 20
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2001 Carelink Health Plans 21 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.
$20 per office visit

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

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

treatment is by open cutting surgery)

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

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

Nothing

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.

Durable medical equipment (DME) You pay
Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as

oxygen and dialysis equipment. Under this benefit, we also cover:
hospital beds;
wheelchairs;
crutches;
walkers;
blood glucose monitors; and
insulin pumps.

Note: Plan physicians are responsible for obtaining all applicable precertifications.

40% member copayment

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.

Nothing 22
22 Page 23 24
2001 Carelink Health Plans 23 Section 5( a)
Home health services (Continued) You pay
Not covered: nursing care requested by, or for the convenience of, the patient or

the patient's family; nursing care primarily for hygiene, feeding, exercising, moving the
patient, homemaking, companionship or giving oral medication.

All charges.

Alternative treatments
Chiropractic Services $20 per office visit
Not covered: Acupuncture
Acupressure
Naturopathic services Hypnotherapy

Biofeedback

All charges.

Educational classes and programs
Coverage is limited to:

High-Risk Pregnancy
Disease Management
Diabetes self-management

Nothing 23
23 Page 24 25
2001 Carelink Health Plans 24 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
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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 (c) for charges associated with the facility (i. e. hospital, surgical

center, etc.).
Plan physicians are responsible for obtaining all applicable precertifications.

I M
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T

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

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

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

Nothing if performed in a hospital;
$10 if performed in your primary care physician office;

$20 if performed in a specialist physician office

Surgical procedures continued on next page. 24
24 Page 25 26
2001 Carelink Health Plans 25 Section 5( b)
Surgical procedures (Continued) You pay
Voluntary sterilization Nothing

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.

Nothing if performed in a hospital;
$10 if performed in your primary care physician office;

$20 if performed in a specialist physician office

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

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

Nothing if performed in a hospital;
$10 if performed in PCP office;
$20 if performed in a specialist physician office

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 25
25 Page 26 27
2001 Carelink Health Plans 26 Section 5( b)
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; 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.

Nothing if performed in a hospital;
$10 if performed in your primary care physician office;

$20 if performed in a specialist physician office

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. 26
26 Page 27 28
2001 Carelink Health Plans 27 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single –Double
Pancreas
Allogenic (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
Note: We use United Resource Network (URN) for all transplants. 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

Not covered: Donor screening tests and donor search expenses, except those
performed for the actual donor Implants of artificial organs

Transplants not listed as covered

All charges 27
27 Page 28 29
2001 Carelink Health Plans 28 Section 5( b)
Anesthesia You pay
Professional services provided in –
Hospital (inpatient)

Nothing

Professional services provided in –
Hospital outpatient department Skilled nursing facility
Ambulatory surgical center Office

Nothing 28
28 Page 29 30
2001 Carelink Health Plans 29 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
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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).

Plan providers are responsible for obtaining all applicable precertifications.

I M
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T

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

general nursing care; and meals and special diets.

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

$100 per admission 29
29 Page 30 31
2001 Carelink Health Plans 30 Section 5( c)
Inpatient hospital (Continued) You pay
Other hospital services and supplies, such as: Operating, recovery, maternity, and other treatment rooms

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

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.

$100 per admission

Not covered: blood and blood derivatives not replaced by the member All charges
Extended care benefits/ skilled nursing care facility benefits You pay
Skilled nursing facility (SNF) 20% member copayment

Not covered: custodial care All charges 30
30 Page 31 32
2001 Carelink Health Plans 31 Section 5( c)
Hospice care You pay
Hospice care Nothing

Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when medically appropriate Nothing 31
31 Page 32 33
2001 Carelink Health Plans 32 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
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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.

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
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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 should notify the Plan within 48 hours. This 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. If
you cannot reach your primary care provider, call Member Services at 1-800-348-2922; we will help you contact your doctor or direct you to the appropriate care.

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.
Emergencies outside our service area: Benefits are available for any medically necessary health services 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. If you cannot reach your primary care provider, call
Member Services at 1-800-348-2922; we will help you contact your doctor or direct you to the appropriate care. 32
32 Page 33 34
2001 Carelink Health Plans 33 Section 5( d)
Benefit Description You pay
Emergency within our service area

Emergency care at a doctor's office $10 per office visit to your primary care physician
$20 per office visit to a specialist

Emergency care at an urgent care center $30 per office visit
Emergency care as an outpatient or inpatient at a hospital, including doctors' services $50 copay (waived if admitted)

Not covered:
Elective care or non-emergency care
All charges.

Emergency outside our service area
Emergency care at an urgent care center $30 per office visit

Emergency care as an outpatient or inpatient at a hospital, including doctors' services $50 copay (waived if admitted)

Not covered:
Elective care or non-emergency care
Emergency care at a doctor's office
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 33
33 Page 34 35
2001 Carelink Health Plans 34 Section 5( d)
Section 5 (e). Mental health and substance abuse benefits
I M
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T

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

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

Here are some important things to keep in mind about these benefits:
All benefits are subject to the definitions, limitations, and exclusions in this brochure.
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

Description You pay
Mental health and substance abuse benefits

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
Medical management

$20 per office 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 hospitalizations, facility based intensive outpatient treatment

$100 per hospital admission 34
34 Page 35 36
2001 Carelink Health Plans 35 Section 5( d)
Not covered : Services we have not approved. Note: OPM will base its review of disputes
about treatment plans on the treatment plan's clinical appropriateness. OPM will
generally not order us to pay or provide one clinically appropriate treatment plan in favor
of another.

All charges.

Preauthorization To be eligible to receive these benefits you must follow your treatment plan and all the following authorization processes:
You can access providers in our Mental Health/ Substance Abuse Network by contacting Customer Service at 1-800-348-2922, or for
direct access to MHNet (Mental Health Network) call 1-800-633-1112. Your Primary Care Physician can also refer you for these services.

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

If changes to this plan's benefit structure for 2001 cause your out-of-pocket
costs for your out-of-network provider to be greater than they were in year 2000.

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

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

How to submit network claims All claims are filed by network providers. 35
35 Page 36 37
2001 Carelink Health Plans 36 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
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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
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A N
T
There are important features you should be aware of. These include:
Who can write your prescription. A licensed plan physician or referral plan doctor must write the prescription.

Where you can obtain them. You must obtain prescriptions at a Plan Participating retail or mail order pharmacies.
We use a formulary.
Drugs are prescribed by Plan doctors and dispensed in accordance with our prescription drug formulary.

Nonformulary drugs will be covered when prescribed by a Plan doctor, subject to the $50 non-formulary copay in retail setting and $100 in mail setting.
Our Prescription Drug Formulary is a list of drugs and other items that we approve for your use and which will be dispensed through Participating pharmacies to members.
We periodically review and modify our formulary. This list of approved drugs is available for review in the participating physician's office.
You may also obtain the formulary list by contacting the Plan's Customer Service Department at 1-800-348-2922 or visiting our web-site at www. carelink. cvty. com
These are the dispensing limitations.
You pay a $10 copay per Generic formulary drug or refill and a $20 copay per name Brand formulary drug and a $50 copay for a Non-Formulary drug at a retail pharmacy.

Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan Participating retail pharmacy will be dispensed up to a 30-day supply.
Selected products or prescription drugs may require prior approval from the Plan.
When generic substitution is permissible, but you or your doctor request the name brand drug, you pay the price difference between the generic drug and name brand drug as well as the appropriate

copay per prescription unit or refill.
Selected FDA approved once-daily drugs will be limited to one pill daily where the total daily dose is available in one pill. For example, drug X comes in 20 mg and 40 mg and is FDA approved to be

taken once daily. Drug X 20 mg will be limited to 30 pills per rx.
In any event, your prescription drug copay will never exceed the retail price of the drug.
Mail Order Pharmacy.
You pay a $10 copay per generic formulary drug or refill and a $20 copay per name brand formulary drug when generic substitution is not permissible and $100 copay for a non-formulary drug at Plan

participating Mail Order Pharmacy.
Maintenance medications are those drugs that are needed for long-term or chronic conditions such as high blood pressure, high cholesterol and diabetes. 36
36 Page 37 38
2001 Carelink Health Plans 37 Section 5( f)
You can get up to a 90-day supply of Plan-approved maintenance medications through our mail-order pharmacy. Controlled Substances, warfarin (Coumadin) and methotrexate (Rheumatrex) are
not allowed by the Plan to be filled at Mail Order Pharmacy.
When you have to file a claim.
If you have to file a reimbursement claim for prescription drugs, contact our Customer Service Department at 1-800-348-2922 to obtain claim forms.

. 37
37 Page 38 39
2001 Carelink Health Plans 38 Section 5( f)
Benefit Description You pay
Covered medications and supplies
We cover the following medications and supplies prescribed by a Plan physician and obtained from a Plan pharmacy or through our mail order

program:
Covered medications and accessories include:
Drugs for which a prescription is required by law
Full range of FDA approved prescriptions for birth control, including but not limited to oral contraceptives, Depo Provera and

contraceptive diaphragms Insulin
Plan approved diabetic supplies, including insulin syringes and needles, blood glucose test strips and lancets
Selected injectables as specified by the Plan (Imitrex, Glucagon and Bee Sting Kits)
Disposable needles and syringes needed to inject covered medication
Note: If there is no generic equivalent available, you will still have to pay the brand name copay.

Limited benefits:
Sexual dysfunction drugs have dispensing limitations. For complete details, please call the Customer Service Department at 1-800-348-

2922.

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, you have to pay the difference in cost between the name brand drug and the generic, even if the physician
specified dispense as written for the brand name drug.

We have a closed formulary. To obtain a formulary list, please call the Customer Service Department at 1-800-348-2922, or visit our
website at www. carelink. cvty. com.

Retail Pharmacy (30-day supply), you pay:
$10 copay for generic
$20 copay for formulary-brand
$50 copay for non-formulary

Mail-Order Pharmacy (90-day supply), you pay:
$10 copay for generic
$20 copay for formulary-brand
$100 for non-formulary 38
38 Page 39 40
2001 Carelink Health Plans 39 Section 5( f)
Not covered:
Drugs available without a prescription or for which there is a nonprescription equivalent available

Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies
Vitamins and minerals (both OTC and legend), except legend prenatal vitamins and liquid or chewable legend pediatric vitamins
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Drugs to aid in smoking cessation
Drugs used for the primary purpose of treating infertility, including those given in connection with artificial insemination

Oral dental preparations and fluoride rinses
Drug therapy for weight loss (e. g., Xenical)
Replacement drugs resulting from loss, damage or theft
Prescriptions directly related to non-covered services or benefits
Any non-covered brand name drug specified by Carelink when the same drug is made by two different brand name manufacturers

All Charges 39
39 Page 40 41
2001 Carelink Health Plans 40 Section 5( g)
Section 5 (g). Special Features
Feature Description
Services for deaf and hearing impaired T. T. D. services are available. For more information, please call
Customer Service at 1-800-348-2922.

Reciprocity benefit Reciprocity benefits are available through Health America. For more information, please call Customer Service at 1-800-348-2922.

High risk pregnancies Carelink offers a healthy pregnancy program for all members, including, intensive case management for high-risk pregnancies. For more information, please call Customer Service at 1-800-348-2922.

Centers of excellence for transplants/ heart
surgery/ etc
Carelink utilizes the United Resources Network for all transplants. For more information, please call Customer Service at 1-800-348-2922.

Travel benefit/ services overseas Emergency care is available worldwide. For more information, please call Customer Service at 1-800-348-2922. 40
40 Page 41 42
2001 Carelink Health Plans 41 Section 5( i)
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.

Plan dentists must provide or arrange your care.
We cover hospitalization for dental procedures only when a non-dental 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
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T
Accidental injury benefit 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.

$20 copay if care is delivered by a dentist or specialist;
$100 copay if care is rendered as an inpatient or outpatient in a hospital

Dental benefits
We have no other dental benefits. 41
41 Page 42 43
2001 Carelink Health Plans 42 Section 8
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.

FEDERAL CARELINK DENTAL PLAN

Federal Carelink Dental is an optional dental product that Carelink complements and supplements the dental benefits included in your Carelink HMO coverage. It is available at no cost when you choose the Carelink HMO
medical option.
To apply for Federal Carelink Dental, you must be enrolled in the Carelink HMO medical option.
Plan Features:
Covers most preventive and basic services Freedom of choice when choosing providers
No deductibles Covers dependent children up to age 22
Easy claims submission
For more information regarding benefits, limitations and exclusions, please call Customer Service at 1-800-348-2922. 42
42 Page 43 44
2001 Carelink Health Plans 43 Section 8
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 and we agree, as discussed under What Services Require Our Prior Approval on page 11.

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;
Procedures, services, drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act

of rape or incest;
Procedures, services, drugs and supplies related to sex transformations;
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program; 43
43 Page 44 45
2001 Carelink Health Plans 44 Section 8
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 or
coinsurance.
You will only need to file a claim when you receive emergency services from non-plan providers. Sometimes these providers bill us directly. Check with the provider. If you need to file the claim, here is the process:

Medical and hospital benefits In most cases, providers and facilities file claims for you. Physicians must file on the form HCFA-1500, Health Insurance Claim Form.
Facilities will file on the UB-92 form. For claims questions and assistance, call us at 1-800-348-2922.

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 of 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: Carelink Health Plans, PO Box 7373, London, KY 40742

Prescription drugs In most cases, participating pharmacy providers file claims for you. If you need to submit a prescription claim for reimbursement, or if you
have questions or need assistance, please call us at 1-800-348-2922.

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. 44
44 Page 45 46
2001 Carelink Health Plans 45 Section 8
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.
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: Carelink Health Plans, 141 Summers Square, Charleston, WV 25326. You must:
(a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: Carelink Health Plans, 141 Summers Square, Charleston, WV 25326; 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 III, P. O. Box 436, Washington, D. C. 20044-0436. 45
45 Page 46 47
2001 Carelink Health Plans 46 Section 8
The Disputed Claims Process (Continued)
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.

Note: You are the only person who has a right to file a disputed claim with OPM. Parties acting as your representative, such as medical providers, must provide a copy of your specific written consent with the
review request.
Note: The above deadlines may be extended if you show that you were unable to meet the deadline because of reasons beyond your control.

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

6 If you do not agree with OPM's decision, your only recourse is to sue. If you decide to sue, you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services, drugs, or supplies. This is the only deadline that may not be extended.
OPM may disclose the information it collects during the review process to support their disputed claim decision. This information will become part of the court record.
You may not sue until you have completed the disputed claims process. Further, Federal law governs your lawsuit, benefits, and payment of benefits. The Federal court will base its review on the record that was
before OPM when OPM decided to uphold or overturn our decision. You may recover only the amount of benefits in dispute.

NOTE: If you have a serious or life threatening condition (one that may cause permanent loss of bodily functions or death if not treated as soon as possible), and
(a) We haven't responded yet to your initial request for care or preauthorization/ prior approval, then call us at 1-800-348-2922 and we will expedite our review; or
(b) We denied your initial request for care or preauthorization/ prior approval, then:
If we expedite our review and maintain our denial, we will inform OPM so that they can give your claim expedited treatment too, or

You can call OPM's Health Benefits Contracts Division III at 202-606-0737 between 8 a. m. and 5 p. m. eastern time. 46
46 Page 47 48
2001 Carelink Health Plans 47 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 or 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. Its 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 coordinated by your Plan PCP and precertified by Carelink as required.

We will not waive any of our copayments or coinsurance.
(Primary payer chart begins on next page.) 47
47 Page 48 49
2001 Carelink Health Plans 48 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 solely because 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………………………………………… …………………….. …….

Please note, if your Plan physician does not participate in Medicare, you will have to file a claim with Medicare 48
48 Page 49 50
2001 Carelink Health Plans 49 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
you 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 1-800-348-2922 or
visit our website at www. carelink. cvty. com.
In this case, we do not waive any out-of-pocket costs.

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+ Choice plan, the following options are available to you:

This Plan and our Medicare managed care plan: You may enroll in our Medicare managed care plan and also remain enrolled in our FEHB
plan. In this case, we do not waive any of our copayments or coinsurance 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, but we will not waive any
of our copayments or coinsurance.
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. For information on suspending your FEHB enrollment,
contact your retirement office. If you later want to re-enroll in the FEHB Program, generally you may do so only at the next open season unless
you involuntarily lose coverage or move out of the Medicare 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.

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. 49
49 Page 50 51
2001 Carelink Health Plans 50 Section 9
Workers' Compensation We do not cover services that:
you need because of a workplace-related disease or injury that the Office of Workers' Compensation Programs (OWCP) or a similar
Federal or State agency determines they must provide; or
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you
filed under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your treatment, we will cover your benefits. You must use our providers.

Medicaid When you have this Plan and Medicaid, we pay first. 50
50 Page 51 52
2001 Carelink Health Plans 51 Section 9
When other Government agencies We do not cover services and supplies when a local, State, are responsible for your care or Federal Government agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you for for injuries medical or hospital care for injuries or illness caused by another person,
you must reimburse us for any expenses we paid. However, we will cover the cost of treatment that exceeds the amount you received in the
settlement.
If you do not seek damages you must agree to let us try. This is called subrogation. If you need more information, contact us for our
subrogation procedures. 51
51 Page 52 53
2001 Carelink Health Plans 52 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 12.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 12.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Custodial care is care designed essentially to assist an individual to meet his/ her activities of daily living.

Experimental or The Medical Director is responsible for the evaluation of new investigational services technologies including medical, surgical, and diagnostic, drugs and
devices, and new applications of existing technologies. New technology and new applications of existing technology must be approved by the
appropriate regulatory body if applicable. The evidence in the literature and the opinions of the relevant medical experts, if available, must show
the new technology or application will improve the health outcome and must be effective as established alternatives. If the above criteria are not
met, the technology or application may be considered experimental or investigational.

Group health coverage Insurance coverage provided to eligible employees or members of an employer, group or association.
Medical necessity Those services/ supplies that we determine to be appropriate and which are provided in accordance with standards of care in the Service Area.

Plan Allowance Amount paid for services that is based on the contract we have with plan providers.
Us/ We Us and we refer to Carelink Health Plans
You You refers to the enrollee and each covered family member. 52
52 Page 53 54
2001 Carelink Health Plans 53 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. 53
53 Page 54 55
2001 Carelink Health Plans 54 Section 11
When benefits and The benefits in this brochure are effective on January 1. If you are new premiums start to this Plan, your coverage and premiums begin on the first day of your first pay
period that starts on or after January 1. Annuitants' premiums begin on January 1.
Your medical and claims We will keep your medical and claims information confidential. Only records are confidential the following will have access to it:

OPM, this Plan, and subcontractors when they administer this contract;
This Plan, and appropriate third parties, such as other insurance plans and the Office of Workers' Compensation Programs (OWCP), when

coordinating benefit payments and subrogating claims;
Law enforcement officials when investigating and/ or prosecuting alleged civil or criminal actions;

OPM and the General Accounting Office when conducting audits;
Individuals involved in bona fide medical research or education that does not disclose your identity; or

OPM, when reviewing a disputed claim or defending litigation about a claim.
When you retire When you retire, you can usually stay in the FEHB Program. Generally, you must have been enrolled in the FEHB Program for the last five years of your
Federal service. If you do not meet this requirement, you may be eligible for other forms of coverage, such as Temporary Continuation of Coverage (TCC).

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

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

Spouse equity If you are divorced from a Federal employee or annuitant, you may not coverage continue to get benefits under your former spouse's enrollment. But, you
may be eligible for your own FEHB coverage under the spouse equity law. If you are recently divorced or are anticipating a divorce, contact
your ex-spouse's employing or retirement office to get RI 70-5, the Guide to Federal Employees Health Benefits Plans for Temporary
Continuation of Coverage and Former Spouse Enrollees, or other information about your coverage choices.

TCC If you leave Federal service, or if you lose coverage because you no longer qualify as a family member, you may be eligible for Temporary
Continuation of Coverage (TCC). For example, you can receive TCC if you are not able to continue your FEHB enrollment after you retire.

You may not elect TCC if you are fired from your Federal job due to gross misconduct.
Get the RI 79-27, which describes TCC, and the RI 70-5, the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of
Coverage and Former Spouse Enrollees, from your employing or retirement office or from www. opm. gov/ insure. 54
54 Page 55 56
2001 Carelink Health Plans 55 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 1-800-348-2922
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. 55
55 Page 56 57
2001 Carelink Health Plans 56 Index
Index Do not rely on this page; it is for your convenience and does not explain your benefit coverage.
Accidental injury 41 Allergy tests 18
Ambulance 31 Anesthesia 28
Autologous bone marrow transplant 27
Biopsies 24 Blood and blood plasma 30
Breast cancer screening 16 Casts 30
Changes for 2001 8 Chemotherapy 19
Childbirth 17 Cholesterol tests 15
Claims 44 Coinsurance 12, 52
Colorectal cancer screening 15 Congenital anomalies 24
Coordination of benefits 47 Covered services 52
Covered providers 5 Crutches 22
Definitions 52 Dental care 41
Diagnostic services 15, 34 Disputed claims review 45
Donor expenses (transplants) 27 Dressings 30
Durable medical equipment (DME) 22
Educational classes and programs 23 Effective date of enrollment 54
Emergency 32 Experimental or investigational 52
Family planning 17 Fecal occult blood test 15
General Exclusions 43 Hearing services 20

Home health services 22 Hospice care 31
Home nursing care 22 Hospital 29
Immunizations 16 Infertility 17
Inhospital physician care 14 Inpatient Hospital Benefits 29
Insulin 38 Laboratory and pathological
services 15 Machine diagnostic tests 15
Magnetic Resonance Imagings (MRIs) 15
Mail Order Prescription Drugs 36 Mammograms 15, 16
Maternity Benefits 17 Medicaid 50
Medically necessary 11 Medicare 47
Mental Conditions/ Substance Abuse Benefits 34
Newborn care 17 Non-FEHB Benefits 42
Nurse Licensed Practical Nurse 22
Nurse Anesthetist 30 Registered Nurse 29
Nursery charges 17 Obstetrical care 17
Occupational therapy 20 Office visits 14
Oral and maxillofacial surgery 26 Orthopedic devices 22
Out-of-pocket expenses 12 Outpatient facility care 30
Oxygen 22 Pap test 15

Physical therapy 20 Physician 14
Pre-admission testing 30 Precertification 11
Preventive care, adult 15 Preventive care, children 16
Prescription drugs 36 Preventive services 15-16
Prior approval 11 Prostate cancer screening 15
Prosthetic devices 22 Psychologist 34
Radiation therapy 19 Rehabilitation therapies 19
Renal dialysis 19 Room and board 29
Second surgical opinion 14 Skilled nursing facility care 30
Speech therapy 20 Splints 30
Subrogation 51 Substance abuse 34
Surgery 24 Anesthesia 28
Oral 26 Outpatient 30
Reconstructive 25 Syringes 38
Temporary continuation of coverage 54
Transplants 27, 40 Treatment therapies 19
Well child care 16 Wheelchairs 22
Workers' compensation 50 X-rays 15 56
56 Page 57 58
2001 Carelink Health Plans 57
NOTES: 57
57 Page 58 59
2001 Carelink Health Plans 58 Summary
NOTES: 58
58 Page 59 60
2001 Carelink Health Plans 59 Summary
Summary of Benefits for Carelink Health Plans -2001 Do not rely on this chart alone. All benefits are provided in full unless otherwise indicated subject to the limitations
and exclusions set forth in 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 & treatment services provided in the office
Office visit copay: $10 primary care; $20

specialist 14-28
Services provided by a hospital:
Inpatient
Outpatient

$100 copayment per admission 29-31

Emergency benefits
In-area
Out-of-area

$50 copayment
(waived if admitted) 32-33

Mental health and substance abuse treatment Regular cost sharing 34-35
Prescription Drugs $10 copay for generic;
$20 for a brand; $50 copay for

all non-formulary drugs. Mail order
prescriptions are available.

formulary-36-39

Dental Care Accidental Benefit only. 41
Vision Care No benefit

Special Features
Services for deaf and hearing impaired
Reciprocity benefit
High risk pregnancies
Centers of excellence for transplants
Travel benefit/ services overseas

Nothing 40

Protection against catastrophic costs (your out-of-pocket maximum) Nothing after
$1500/ Self Only or $3000/ Family

enrollment per year. Some costs do not
count toward this protection.

12 59
59 Page 60
2001 Carelink Health Plans 60 Summary
2001 Rate Information for Carelink Health Plans
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

Fill in Location Here
Self Only 4C1 $81.21 $27.07 $175.96 $58.65 $96.10 $12.18

Self and Family 4C2 $195.82 $123.25 $424.28 $267.04 $231. 17 $87.90 60

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