Pages 1--56 from CapitalCare

This Plan has commendable accreditation
from NCQA. See the 2001 Guide
for more information on NCQA.

Enrollment codes for this Plan: 2G1 Self Only
2G2 Self and Family

RI 73-718

For changes
in benefits
see page 7 1
1 Page 2 3
2001 CapitalCare, Inc. 2 Table of Contents
Table of Contents
Introduction…………………………………………………………………................................................................. 4
Plain Language………………………………………………………………................................................................ 4
Section 1. Facts about this HMO plan ........................................................................................................................... 5
How we pay providers .................................................................................................................................. 5
Who provides my health care?...................................................................................................................... 5
Patients' Bill of Rights................................................................................................................................... 5
Service Area .................................................................................................................................................. 6
Section 2. How we change for 2001……………………………………….. ................................................................ 7
Program-wide changes .................................................................................................................................. 7
Changes to this Plan ...................................................................................................................................... 7
Section 3. How you get care …………... ...................................................................................................................... 8
Identification cards........................................................................................................................................ 8
Where you get covered care.......................................................................................................................... 8

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

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

Copayments .......................................................................................................................................... 11
Deductible............................................................................................................................................. 11
Coinsurance .......................................................................................................................................... 11
Your out-of-pocket maximum..................................................................................................................... 11
Section 5. Benefits………………………………………………………… ............................................................... 12
Overview..................................................................................................................................................... 12
(a) Medical services and supplies provided by physicians and other health care professionals ........... 13
(b) Surgical and anesthesia services provided by physicians and other health care professionals........ 23
(c) Services provided by a hospital or other facility, and ambulance services...................................... 27
(d) Emergency services/ accidents.......................................................................................................... 30
(e) Mental health and substance abuse benefits..................................................................................... 33
(f) Prescription drug benefits................................................................................................................. 35
(g) Special features................................................................................................................................. 38
(h) Dental benefits.................................................................................................................................. 39 2
2 Page 3 4
2001 CapitalCare, Inc. 3 Table of Contents
(i) Non-FEHB benefits available to Plan members............................................................................... 40
Section 6. General exclusions --things we don't cover .............................................................................................. 41
> Section 7. Filing a claim for covered services ............................................................................................................. 42
Section 8. The disputed claims process........................................................................................................................ 43
Section 9. Coordinating benefits with other coverage ................................................................................................. 45
When you have…

Other health coverage .......................................................................................................................... 45
Original Medicare ................................................................................................................................ 45
Medicare managed care plan................................................................................................................ 47
TRICARE/ Workers' Compensation/ Medicaid........................................................................................... 48
Other Government agencies ....................................................................................................................... 48
When others are responsible for injuries.................................................................................................... 48
Section 10. Definitions of terms we use in this brochure............................................................................................. 49
Section 11. FEHB facts ................................................................................................................................................ 50

Coverage information.............................................................................................................................. 50
No pre-existing condition limitation ................................................................................................. 50
Where you get information about enrolling in the FEHB Program.................................................. 50
Types of coverage available for you and your family ...................................................................... 50
When benefits and premiums start.................................................................................................... 51
Your medical and claims records are confidential............................................................................ 51
When you retire................................................................................................................................ 51
When you lose benefits ............................................................................................................................ 51

When FEHB coverage ends ............................................................................................................... 51
Spouse equity coverage..................................................................................................................... 51
Temporary Continuation of Coverage (TCC)................................................................................... 51
Converting to individual coverage.................................................................................................... 52
Getting a Certificate of Group Health Plan Coverage ...................................................................... 52

Inspector General Advisory........................................................................................................................................... 52
Index.............................................................................................................................................................................. 53
Summary of benefits ..................................................................................................................................................... 63
Rates………………………………………………………………………………………………………… Back cover 3
3 Page 4 5
2001 CapitalCare, Inc. 4 Introduction/ Plain Language
Introduction
CapitalCare, Inc.
550 12 th Street S. W.
Washington D. C. 20065

This brochure describes the benefits of CapitalCare, Inc. under our contract (CS 2797) 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 63. 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 CapitalCare, Inc.

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 CapitalCare, Inc. 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.

Who provides my health care?
Since we are an Individual Practice Association (IPA) model HMO, you receive care from a network of physicians
who practice in their private offices. Our network consists of 38 hospitals, over 1,340 primary care doctors and over
3,814 specialists at more than 10,000 locations. In addition, our plan has designated facilities for diagnostic radiology
and laboratory services. As a member, you may choose your own primary care doctor from our Provider Directory.

If you think you need mental health and substance abuse treatment, you should first contact our vendor Health
Management Strategies [HMS] (or other vendor we determine) at 703/ 739-2434 or 800/ 822-4614. If you need
treatment, HMS will refer you to one of their network providers. HMS, not your primary care doctor, must coordinate
all your mental health and substance abuse services.

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.

We are in compliance with Federal and State licensing and certification requirements We have been in existence since 1984
We are a for profit corporation
If you want more information about us, call 800/ 680-9495, 202/ 479-3708, or write to CapitalCare Inc., 550 12 th Street,
S. W., Washington, DC 20065. You may also contact us by fax at 202/ 479-1300 or visit our website at
www. carefirst. com. 5
5 Page 6 7
2001 CapitalCare, Inc. 6 Section 1
Service Area
To enroll in this Plan, you must live in or work in our Service Area.

Our service area is: The District of Columbia; the Maryland counties of Calvert, Howard, Montgomery, and Prince
Georges, and portions of the Maryland counties of Anne Arundel, Carroll, Charles, Frederick and St. Mary's within
the zip codes listed below; the Virginia counties of Arlington, Fairfax, Fauquier, Lounden, Prince William,
Spotsylvania, and Stafford, plus the cities of Alexandria, Falls Church and Fredericksburg.

You may also enroll with us if you live or work in the following zip codes:
Anne Arundel: 20711, 20724, 20733, 20751, 20754-5, 20758, 21764-5, 20776, 20778-9, 20794, 21032, 21035, 21037,
21054, 21060-2, 21076-7, 21090, 21098, 21106, 21108, 21113-4, 21140, 21144, 21225, 21240, 21401-5, 21411-12

Carroll: 21080, 21104, 21764, 21771, 21776, 21784, 21791-2, 21797
Charles: 20601-4, 20607, 20611-13, 20616-17, 20622, 20632, 20637, 20640, 20643, 20646, 20658, 20662, 20675,
20677, 20693, 20695

Frederick: 21701-2, 21703, 21704, 21705, 21709-10, 21714-18, 21736, 21754-59, 21762, 21769-71, 21773-78,
21788, 21790-91, 21792, 21793, 21798

St. Mary's: 20622, 20635, 20659-60. 6
6 Page 7 8
2001 CapitalCare, Inc. 7 Section 2
Section 2. How we change for 2001
Program-wide changes
The plain language team reorganized the brochure and the way we describe our benefits. We hope this will make it easier for you to compare plans.

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

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

patient safety activities by calling 800/ 680-9495, or checking our website www. carefirst. 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 25.4% for Self Only or 0.6% for Self and Family. Under allergy testing and treatment, you now pay a $10 copay for office visits, $25 copay per testing series, and
nothing for allergy serum that you receive at the doctors office. Previously, you paid a $25 copay per visit. See
page 17.

You now pay an $8 generic drug copay, $15 copay for prescriptions on the Plan's formulary brand name list, and a $30 copay for all other prescriptions. Previously, you paid a $5 copay for generic drugs and $10 copay for

brand name drugs. See page 36.
For mail order prescriptions, you now pay a $16 copay for generic drugs, $30 copay for drugs on the Plan's formulary brand name list, and $60 copay for all other prescription drugs for a 90 day supply. Previously, you

paid a $10 copay for generic prescriptions and $20 copay for brand name drugs. See page 36.
We are now using a new vision vendor. See the updated CapitalCare directory for a list of vision care centers. 7
7 Page 8 9
2001 CapitalCare, Inc. 8 Section 3
Section 3. How you get care
Identification cards We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it
whenever you receive services from a Plan provider, or fill a prescription
at a Plan pharmacy. Until you receive your ID card, use your copy of the
Health Benefits Election Form, SF-2809, your health benefits enrollment
confirmation (for annuitants), or your Employee Express confirmation
letter.

If you do not receive your ID card within 30 days after the effective date
of your enrollment, or if you need replacement cards, call us at 800/ 680-
9495 or 202/ 479-3708.

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

Plan providers Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our
members. We credential Plan providers according to national standards.
We list Plan providers in the provider directory, which we update
periodically. The list is also on our website.

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

What you must do It depends on the type of care you need. First, you and each family member must choose a primary care physician. This decision is
important since your primary care physician provides or arranges for
most of your health care. Each member may choose his or her own
primary care doctor from our Provider Directory.

Primary care Your primary care physician can be a family practitioner, general practitioner, internist, or pediatrician. Your primary care physician will
provide most of your health care, or give you a referral to see a specialist.
If you want to change primary care physicians or if your primary care
physician leaves the Plan, call us. We will help you select a new one.

Specialty care Your primary care physician will refer you to a specialist for needed care. However, you may see your Plan gynecologist for a routine visit 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 work with the Plan to develop a treatment plan that allows you to
see your specialist for a certain number of visits without additional
referrals. Your primary care physician will use our criteria when
creating your treatment plan (the physician may have to get an
authorization or approval beforehand). 8
8 Page 9 10
2001 CapitalCare, Inc. 9 Section 3
If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide
what treatment you need. If he or she decides to refer you to a
specialist, ask if you can see your current specialist. If your current
specialist does not participate with us, you must receive treatment
from a specialist who does. Generally, we will not pay for you to see
a specialist who does not participate with our Plan.

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

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

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

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

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

Hospital care Your Plan primary care physician or specialist will make necessary hospital arrangements and supervise your care. This includes admission
to a skilled nursing or other type of facility.
If you are in the hospital when your enrollment in our Plan begins, call
our customer service department immediately at 800/ 680-9495 or
202/ 479-3708. 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. 9
9 Page 10 11
2001 CapitalCare, Inc. 10 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 pre-authorization. Your
physician must obtain pre-authorization for the following services such
as:

Inpatient services Outpatient services
Hospice care Skilled nursing facility
Home health care Mental health/ substance abuse services
Intravenous (IV)/ Infusion Therapy -Home IV and antibiotic therapy Growth Hormone Therapy
Dialysis in a hospital setting
Your primary care physician will contact us for pre-authorization or an
extension of a pre-authorized service. Your services may be denied if
pre-authorization is not obtained. 10
10 Page 11 12
2001 CapitalCare, Inc. 11 Section 4
Section 4. Your costs for covered services
You must share the cost of some services. You are responsible for:
Copayments A copayment is a fixed amount of money you pay to the provider when you receive services.

Example: When you see your primary care physician you pay a
copayment of $10 per office visit.

Deductible We do not have a deductible

Coinsurance We do not have coinsurance.
Your out-of-pocket maximum After your copayments total $1,900 per person or $5,500 per family enrollment in any calendar year, you do not have to pay any more for
covered services. However, copayments for the following services do not
count toward your out-of-pocket maximum, and you must continue to pay
copayments for these services:

Prescription drugs
Vision benefits
Be sure to keep accurate records of your copayments since you are
responsible for informing us when you reach the maximum. 11
11 Page 12 13
2001 CapitalCare, Inc. 12 Section 5
Section 5. Benefits – OVERVIEW
(See page 7 for how our benefits changed this year and page 63 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 800/ 680-9495 or 202/ 479-3708 or at our website at www. carefirst. com.

(a) Medical services and supplies provided by physicians and other health care professionals...................................... 13-22
Diagnostic and treatment services Lab, X-ray, and other diagnostic tests

Preventive care, adult Preventive care, children
Maternity care Family planning
Infertility services Allergy care
Treatment therapies Rehabilitative therapies

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

(b) Surgical and anesthesia services provided by physicians and other health care professionals ....................... 23-26
Surgical procedures Reconstructive surgery Oral and maxillofacial surgery Organ/ tissue transplants
Anesthesia
(c) Services provided by a hospital or other facility, and ambulance services ..................................................... 27-29

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

(d) Emergency services/ accidents .................................................................................................................. 30-32
Medical emergency Ambulance

(e) Mental health and substance abuse benefits ............................................................................................. 33-34
(f) Prescription drug benefits ................................................................................................................................ 35-37
(g) Special features ...................................................................................................................................................... 38
24 hour nurse line

(h) Dental benefits ....................................................................................................................................................... 39
(i) Non-FEHB benefits available to Plan members .................................................................................................... 40

Summary of benefits ..................................................................................................................................................... 55 12
12 Page 13 14
2001 CapitalCare, Inc. 13 Section 5( a)
Section 5 (a) Medical services and supplies provided by physicians and other health care professionals
I M
P O
R T
A N
T

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

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

coverage, including with Medicare.

I M
P O
R T
A N
T

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

$10 per visit

Professional services of physicians
In a Plan urgent care center
Initial examination of a newborn child covered under a family enrollment

Office medical consultations
Second surgical opinion
At home

$10 per visit

During a hospital stay
In a skilled nursing facility Nothing

Diagnostic and treatment services --Continued on next page 13
13 Page 14 15
2001 CapitalCare, Inc. 14 Section 5( a)
Diagnostic and treatment services (Continued) You pay
Not covered:
Tests and/ or services not medically necessary; or experimental
Test required for marriage; employment; foreign travel; or
government licensing

All charges

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

Nothing, if these services are
rendered at an approved
radiological provider or approved
laboratory.

Preventive care, adult
Routine screenings, such as:
Blood lead level – One annually

Total Blood Cholesterol – annually
Colorectal Cancer Screening, including
Fecal occult blood test

Nothing, if these services are
rendered at an approved
laboratory.

Sigmoidoscopy, screening – every five years starting at age 50 Nothing, if these services are rendered at an approved
laboratory.

Prostate Specific Antigen (PSA test) – one annually for men age 40 and older Nothing, if these services are
rendered at an approved
laboratory.

Routine pap test
Note: The office visit is covered at a $10 copay if pap test is received
on the same day

Nothing, if these services are
rendered at an approved
laboratory.

Preventive Care, Adult— Continued on next page 14
14 Page 15 16
2001 CapitalCare, Inc. 15 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

Nothing, if these services are
rendered at an approved radiology
provider.

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

Nothing if you receive these
services through a well child visit
or a complete physical. Otherwise,
$10 per visit.

Not covered: Immunizations for the purpose of school, work, or travel All charges
Preventive care, children

Childhood immunizations recommended by the American Academy of Pediatrics $10 per visit

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 visit at participating vision
centers or $25 per visit at
participating opthalmologists with
a referral

$10 per visit 15
15 Page 16 17
2001 CapitalCare, Inc. 16 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 10 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).

$10 per visit ($ 100 copay
maximum per pregnancy)

Not covered: Routine sonograms to determine fetal age, size or sex All charges
Family planning
Voluntary sterilization
Surgically implanted contraceptives
Injectable contraceptive drugs
Intrauterine devices (IUDs)

$10 per visit

Not covered: reversal of voluntary surgical sterilization, genetic
counseling,
All charges 16
16 Page 17 18
2001 CapitalCare, Inc. 17 Section 5( a)
Infertility services You pay
Diagnosis and treatment of infertility, such as:
Artificial insemination:
intravaginal insemination (IVI)
intracervical insemination (ICI)
intrauterine insemination (IUI)
Fertility drugs
Note: We cover oral fertility drugs under the prescription drug benefit.

$10 per visit

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

Cost of donor sperm

All charges

Allergy care
Testing and treatment
Allergy injection
$25 per testing series

$10 per visit

Allergy serum Nothing
Not covered: provocative food testing and sublingual allergy
desensitization
All charges 17
17 Page 18 19
2001 CapitalCare, Inc. 18 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 26.

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

Growth hormone therapy (GHT)

Note: – We will only cover GHT when we preauthorize the treatment.
Call Advance Secure at 800/ 294-5979 for preauthorization. We will
ask you to submit information that establishes that the GHT is
medically necessary. Ask us to authorize GHT before you begin
treatment; otherwise, we will only cover GHT services from the date
you submit the information. If you do not ask or if we determine GHT
is not medically necessary, we will not cover the GHT or related
services and supplies. See Services requiring our prior approval in
Section 3.

$10 per visit

Not covered:
Experimental or investigative services
Services that are not medically necessary

All charges 18
18 Page 19 20
2001 CapitalCare, Inc. 19 Section 5( a)
Rehabilitative therapies You pay
Physical therapy, occupational therapy and speech therapy --
Up to two consecutive months per condition for the services of each of the following if significant improvement can be expected within

90 days:
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.

Note: Occupational therapy is limited to services which assist the
member to achieve and maintain self-care and improved
functioning in other activities of daily living.

$10 per visit

Not covered:
Long-term rehabilitative therapy
Exercise program
Cardiac rehabilitation
Chiropractic services

All charges

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

Note: Adult hearing tests are covered only if referred by a PCP.

$10 per visit

Not covered:
all other hearing testing hearing aids, testing and examinations for them All charges 19
19 Page 20 21
2001 CapitalCare, Inc. 20 Section 5( a)
Vision services (testing, treatment, and supplies) You pay
One pair of eyeglasses or contact lenses to correct an impairment directly related to intraocular surgery (such as for cataracts) $10 per visit

Eye exam (exam by ophthalmologist requires a referral) to determine the need for vision correction for children and adults (see preventive
care)

$10 per visit at participating vision
centers or $25 per visit at participating
opthalmologists

Daily wear contact lens exam and fittings $48 per visit and three follow-up fittings

Disposable contact lens exam, fitting and one year follow-up $78 per visit (includes fitting and follow-up)
Not covered:
Eyeglasses or contact lenses
Eye exercises and orthoptics
Radial keratotomy and other refractive surgery

All charges

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

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

$10 per visit

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

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

treatment is by open cutting surgery)

All charges 20
20 Page 21 22
2001 CapitalCare, Inc. 21 Section 5( a)
Orthopedic and prosthetic devices You pay
Externally worn breast prostheses and surgical bras, including necessary replacements, following a mastectomy

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

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

$10 per visit

Not covered:
Orthopedic and corrective shoes
Arch supports
Foot orthotics
Heel pads and heel cups
Lumbosacral supports
Corsets, trusses, elastic stockings, support hose, and other supportive devices

Prosthetic devices, such as artificial limbs and lenses following cataract removal
Prosthetic replacements provided less than 3 years after the last one we covered

All charges

Durable medical equipment (DME)
No benefit No benefit

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

Home Health Services— continued on next page 21
21 Page 22 23
2001 CapitalCare, Inc. 22 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
No benefit No benefit

Diabetic services
Coverage is limited to:
Diabetes equipment and supplies Diabetes self-management training and educational services and

nutrition therapy.

Note: Self-management training and educational services must be
supervised by an appropriately licensed, registered, or certified health
care provider whose scope of practice includes diabetes education and
management.

Note: Certain diabetes supplies are covered under the prescription
benefit and subject to prescription copays.

Note: Certain diabetes supplies such as insulin pumps and glucometers
are covered under the medical coverage and you will need to file a claim
with us for reimbursement.

$10 copay

Not covered: Services related to the treatment of diabetes other than types I
and II. All charges

Educational classes and programs
Coverage is limited to:

Diabetes self-management (Sponsored by the Plan's Health Education Department) None 22
22 Page 23 24
2001 CapitalCare, Inc. 23 Section 5( b)
Section 5 (b). Surgical and anesthesia services provided by physicians and other health care professionals
I M
P O
R T
A N
T

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

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

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

center, etc.).
YOUR PROVIDER MUST GET PRECERTIFICATION OF SURGICAL PROCEDURES. Please refer to the precertification information shown in Section 3 to be sure which services require

precertification and identify which surgeries require precertification.

I M
P O
R T
A N
T

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

Correction of amblyopia and strabismus Endoscopy procedure
Biopsy procedure Removal of tumors and cysts
Correction of congenital anomalies (see reconstructive surgery)
Surgical treatment of morbid obesity --a condition in which an individual weighs 100 pounds or 100% over his or her normal

weight according to current underwriting standards; eligible
members must be age 18 or over

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

$10 per office or outpatient visits;
nothing for inpatient visits

Surgical procedures continued on next page. 23
23 Page 24 25
2001 CapitalCare, Inc. 24 Section 5( b)
Surgical procedures (Continued) You pay
Voluntary sterilization Norplant (a surgically implanted contraceptive) and intrauterine
devices (IUDs) Note: Devices are covered under 5( a).
Treatment of burns

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

$10 per office or outpatient visits;
nothing for inpatient visits

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

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

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

$10 per office or outpatient visits;
nothing for inpatient visits

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.

See above.

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

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

All charges 24
24 Page 25 26
2001 CapitalCare, Inc. 25 Section 5( b)
Oral and maxillofacial surgery You pay
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.

$10 per office or outpatient visits;
nothing for inpatient visits

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 25
25 Page 26 27
2001 CapitalCare, Inc. 26 Section 5( b)
Organ/ tissue transplants You pay
Limited to:
Cornea
Heart
Heart/ lung
Kidney
Kidney/ Pancreas
Liver
Lung: Single –Double
Pancreas
Allogeneic (donor) bone marrow transplants

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

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

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

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

Nothing if provided in an inpatient
setting. Otherwise, $10 per visit.

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

Implants of artificial organs
Transplants not listed as covered

All charges

Anesthesia
Professional services provided in –

Hospital (inpatient)
Nothing

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

Nothing 26
26 Page 27 28
CapitalCare, Inc. 27 Section 5( c)
Section 5 (c). Services provided by a hospital or other facility, and ambulance services
I M
P O
R T
A N
T

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

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

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).

YOUR PROVIDER MUST GET PRECERTIFICATION OF HOSPITAL STAYS. Please refer to Section 3 to be sure which services require

precertification.

I M
P O
R T
A N
T

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

Meals and special diets.

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

Nothing

Inpatient hospital continued on next page. 27
27 Page 28 29
CapitalCare, Inc. 28 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, rest cures, domiciliary or convalescent care Non-covered facilities, such as nursing homes, extended care

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

Private nursing care
.

All charges

Outpatient hospital or ambulatory surgical center
Operating, recovery, and other treatment rooms Prescribed drugs and medicines

Diagnostic laboratory tests, X-rays, and pathology services Administration of blood, blood plasma, and other biologicals
Blood and blood plasma, if not donated or replaced Pre-surgical testing
Dressings, casts, and sterile tray services Medical supplies, including oxygen
Anesthetics and anesthesia service
NOTE: – We cover hospital services and supplies related to dental
procedures when necessitated by a non-dental physical impairment. We
do not cover the dental procedures.

$10 copay

Not covered: blood and blood derivatives not replaced by the member All charges 28
28 Page 29 30
CapitalCare, Inc. 29 Section 5( c)
Extended care benefits/ skilled nursing care facility benefits You Pay
If a Plan doctor determines that you need full-time skilled nursing care or need
to stay in a skilled nursing facility, and we approve that decision, we will give
you the comprehensive range of benefits with no dollar or day limit.

Bed, board and general nursing care Drugs, biologicals, supplies, and equipment ordinarily provided or
arranged by the skilled nursing facility when prescribed by a Plan doctor.

Nothing

Not covered: custodial care All charges
Hospice care
If terminally ill, you are covered for supportive and palliative care in
your home or at a hospice. This includes inpatient and outpatient care
and family counseling. A Plan doctor, who certifies that you are in the
terminal stages of illness, with a life expectancy of approximately six
months or less, will direct these services.

Nothing

Not covered: Independent nursing, homemaker services All charges
Ambulance
Local professional ambulance service when medically appropriate Nothing 29
29 Page 30 31
2001 CapitalCare, Inc. 30 Section 5( d)
Section 5 (d). Emergency services/ accidents
I M
P O
R T
A N
T

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

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

coverage, including with Medicare.

I M
P O
R T
A N
T
What is a medical emergency?
A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe
endangers your life or could result in serious injury or disability, and requires immediate medical or
surgical care. Some problems are emergencies because, if not treated promptly, they might become more
serious; examples include deep cuts and broken bones. Others are emergencies because they are
potentially life-threatening, such as heart attacks, strokes, poisonings, gunshot wounds, or sudden inability
to breathe. There are many other acute conditions that we may determine are medical emergencies – what
they all have in common is the need for quick action.

What to do in case of emergency:
Emergencies within our service area: For emergencies, please call your primary care physician. If your PCP is unavailable, call FirstHelp at
800/ 535-9700 and a registered nurse will give you health care advice. In extreme emergencies, where your
life or limbs are in jeopardy, and you cannot reach your doctor, contact the local emergency system (911, for
example) or go to the nearest hospital emergency room. Be sure to tell the workers in the emergency room
that you are a Plan member so they can notify the Plan

If you need to stay in a facility our plan does not designate (a non-Plan facility), you must notify the Plan at
800/ 367-1799 or 202/ 646-0090 within 48 hours or on the first working day after the day they admitted you,
unless you cannot reasonably do so. If you stay in a non-Plan facility and a Plan doctor believes that a Plan
hospital can give you better care, then the facility will transfer you when medically feasible and we will fully
cover any ambulance charges.

You can receive benefits for care from non-Plan providers if you did not reach a Plan provider in time and the
delay would result in death, disability or significantly jeopardize your condition.

For this Plan to cover you, only Plan-providers can give you follow-up care that the non-Plan providers
recommend.

Emergency Services— continued on next page 30
30 Page 31 32
2001 CapitalCare, Inc. 31 Section 5( d)
Emergency Services (Continued)
Emergencies outside our service area: You can receive benefits for any medically necessary health service that you require immediately because of
injury or unforeseen illness.

For emergencies, please contact FirstHelp at 800/ 535-9700 and a registered nurse will give you health care
advice. In extreme emergencies, where your life or limbs are in jeopardy, contact the local emergency system
(911, for example) or go to the nearest hospital emergency room.

If you need to stay in a medical facility, you must notify the Plan at 800/ 367-1799 or 202/ 646-0090 within 48
hours or on the first working day after the date they admit you, unless not reasonably possible to do so. If a
Plan doctor believes a Plan hospital can give you better care, then the facility will transfer you when medically
feasible, and we will fully cover any ambulance charges.

For this Plan to cover you, Plan providers must provide any of the follow-up care that non-Plan providers may
recommend to you. 31
31 Page 32 33
2001 CapitalCare, Inc. 32 Section 5( d)
Benefit Description You pay
Emergency within our service area

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

$10 per visit
$25 per non-participating
urgent
care center visit;
$10 per
participating urgent
care center visit;

$25 per hospital
emergency room
visit.

Note: Copay waived if
admitted into the
hospital

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

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

$10 per visit
$25 per hospital
emergency room or
urgent care center
visit.

Note: Copay waived if
admitted into the
hospital

Not covered:
Elective care or non-emergency care
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

Medical and hospital costs resulting from a normal full-term delivery of a baby outside the service area

All charges

Ambulance
Professional ambulance service when medically appropriate.
See 5( c) for non-emergency service.
Nothing

Not covered: air ambulance All charges 32
32 Page 33 34
2001 CapitalCare, Inc. 33 Section 5( e)
Section 5 (e). Mental health and substance abuse benefits
I M
P O
R T
A N
T

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

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

Here are some important things to keep in mind about these benefits:

All benefits are subject to the definitions, limitations, and exclusions in this brochure.
We have no calendar year deductible.

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

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

I M
P O
R T
A N
T

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

Medication management

$10 per visit

Mental health and substance abuse benefits – Continued on next page 33
33 Page 34 35
2001 CapitalCare, Inc. 34 Section 5( e)
Mental health and substance abuse benefits (Continued) You pay
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
hospitlization, facility based intensive outpatient treatment.

Nothing
$10 per visit

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:
We administer mental health and substance abuse benefits under a contract
with Health Management Strategies [HMS] (or another vendor we
determine). If you think you need mental health or substance abuse
services you must first call HMS at 703/ 739-2434 or 800/ 822-4614. If you
need treatment, HMS will refer you to one of their network providers.
HMS must coordinate all mental health and substance services, not your
primary care doctor.

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

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

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

Limitation We may limit your benefits if you do not follow your treatment plan. 34
34 Page 35 36
2001 CapitalCare, Inc. 35 Section 5( f)
Section 5 (f). Prescription drug benefits
I M
P O
R T
A N
T

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

All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable only when we determine they are medically necessary.
We have no deductible
Certain drugs require clinical prior authorization. Contact the Plan for a listing of which drugs are subject to the prior authorization policy. Prior authorization

may be initiated by the Prescriber or the pharmacy by calling Advance Secure
at 800/ 294-5979 (or other vendor as determined by the Plan)

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

other coverage, including with Medicare.

I M
P O
R T
A N
T

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

Where you can obtain them. You must fill the prescription at a Plan pharmacy, or by mail for a maintenance medication.

We use a formulary. A formulary is a preferred list of drugs that we selected to meet patient needs at a lower cost The formulary includes both generic and brand name drugs. You will be responsible
for higher charges if your doctors prescribes a drug not on our formulary list.

These are the dispensing limitations. You can receive up to 34 days worth of medication for each fill of non-maintenance prescriptions at a local Plan pharmacy. In addition, you can receive up to 90 days
of medications through our mail order pharmacy program. Your copay will be $8, $15, or $30 for a 34-
day supply or less at the retail pharmacy and twice that amount for 35-day supply or greater up to 90
days by mail. The same prescriptions can be purchased through the mail order service as your
community pharmacy. In most cases, you can get a refill once you have taken 75% of the medication.
Your prescription will not be refilled prior to the 75% usage guidelines.

When you have to file a claim. Call our preferred drug vendor, Advanced Paradigm, at 800/ 241-3371 to order prescription drug claim forms. You will send the prescription drug claim
form to: Advance Paradigm, PO Box 853901, Richardson TX 75085-3901.

Prescription drug benefits begin on the next page. 35
35 Page 36 37
2001 CapitalCare, Inc. 36 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:

Drugs and medicines that by Federal law of the United States require a physician's prescription for their purchase, except as excluded below.
Insulin Disposable needles and syringes for the administration of covered
medications
Drugs for sexual dysfunction (Subject to dosage limitations. Contact the Plan for these limitations)

Contraceptive drugs and devices Smoking deterrents
Diabetic supplies, including insulin syringes, needles, glucose test strips, lancets and alcohol swabs

Allergy serum
Note: Intravenous fluids and medications for home use, implantable drugs
(such as Norplant), some injectable drugs (such as Depo Provera), and IUDs
are covered under the Medical and Surgical Benefits.

Note: Injectable coverage will be limited to those medications that are usually
self-injected.

$ 8 per unit or refill for generic
prescriptions

$ 15 per unit or refill for
prescriptions on the Plan's
formulary brand name list

$ 30 per unit or refill for all other
prescripitons

Note: You may use the Plan's mail
service and receive a 90-day supply
for two copayments.

Nothing

Prescription drug benefits ---continued on next page. 36
36 Page 37 38
2001 CapitalCare, Inc. 37 Section 5( f)
Covered medications and supplies (continued) You pay
Here are some things to keep in mind about our prescription drug
program:

We have an open formulary. If your physician believes a name brand product is necessary or there is no generic available, your
physician may prescribe a name brand drug from a formulary list.
This list of name brand drugs is a preferred list of drugs that we
selected to meet patient needs at a lower cost. To order a
prescription drug brochure, call 800/ 241-3371.

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

Nonprescription medicines
Drugs obtained at a non-Plan pharmacy except for out-of-area emergencies

Medical supplies such as dressings and antiseptics
Drugs to enhance athletic performance
Drugs for weight loss

All Charges 37
37 Page 38 39
2001 CapitalCare, Inc. 38 Section 5( g)
Section 5 (g). Special Features
Feature Description

24 hour nurse line If you have any health concerns, call FirstHelp at 1-800-535-9700, 24 hours a day, 7 days a week and talk with a registered nurse who will
discuss treatment options and answer your health questions. 38
38 Page 39 40
2001 CapitalCare, Inc. 39 Section 5( h)
Section 5 (h). Dental benefits
I M
P O
R T
A N
T

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

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

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

I M
P O
R T
A N
T

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

$10 per visit

Dental benefits
We have no other dental benefits. 39
39 Page 40 41
2001 CapitalCare, Inc. 40 Section 5( I)
Section 5 (i). Non-FEHB benefits available to Plan members
The benefits on this page are not part of the FEHB contract or premium, and you cannot file an FEHB disputed
claim about them. Fees you pay for these services do not count toward FEHB deductibles or out-of-pocket maximums.

Dental care
What is covered
The following preventive and diagnostic services are covered when provided by Plan dentists; you pay a $14 adult
copay or a $10 child copay per visit:
° Oral examinations
° Prophylaxis, or cleaning (every 6 months)
° Fluoride treatment
° Pulp Vitality tests
° Diagnostic casts
° Oral Hygiene instruction

You pay 50% of your participating dentist's usual and customary fees for:
° X-rays
° Fillings
° Sealants

For all other non-accidental services under this program, you pay 75% of the participating dentist's usual and
customary fees, including:

° Restorations
° Crown and bridge services
° Endodontic services
° Periodontics
° Prosthodontics, removables
° Oral surgery services
° Broken appointment fee
° Orthodontic services
° TMJ treatment
° Cosmetic and anesthetic services

CareFirst Options
As a member of a CareFirst BlueCross BlueShield HMO, you can receive 25% discounts on alternative therapies
including acupuncture, massage therapy and chiropractic care. You can also receive discounts for fitness centers
including personal trainers, spas and yoga classes. There are no claim forms, referrals or other paperwork for you
to fill out. Just show your FreeState ID card at the time you receive service and you will get the discount. Please
call CareFirst Options Member Services at 888/ 999/ 4140 for additional information and a list of practitioners in
your area. 40
40 Page 41 42
2001 CapitalCare, Inc. 41 Section 6
Section 6. General exclusions – things we don't cover
The exclusions in this section apply to all benefits. Although we may list a specific service as a benefit, we
will not cover it unless your Plan doctor determines it is medically necessary to prevent, diagnose, or treat your illness disease, injury or condition and we agree, as discussed under What Services Require

Our Prior Approval on page 10.

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

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

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

incest;
Services, drugs, or supplies related to sex transformations; or
Services, drugs, or supplies you receive from a provider or facility barred from the FEHB Program. 41
41 Page 42 43
2001 CapitalCare, Inc. 42 Section 7
Section 7. Filing a claim for covered services
When you see Plan physicians, receive services at Plan hospitals and facilities, or obtain your prescription drugs at
Plan pharmacies, you will not have to file claims. Just present your identification card and pay your copayment,
coinsurance, or deductible.

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

Medical, hospital and
drug 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 800/ 680-9495 or 202/ 479-3708

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

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

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

Receipts, if you paid for your services.
Submit your claims to:
CapitalCare Inc, 550 12 th Street SW, Washington DC 20065

Prescription drugs Submit your claims to:
Advance Paradigm Inc, PO Box 853901, Richardson TX 75085-3901

Deadline for filing your claim Send us all of the documents for your claim as soon as possible. You must submit the claim by December 31 of the year after the year you
received the service, unless timely filing was prevented by administrative
operations of Government or legal incapacity, provided the claim was
submitted as soon as reasonably possible.

When we need more information Please reply promptly when we ask for additional information. We may delay processing or deny your claim if you do not respond. 42
42 Page 43 44
2001 CapitalCare, Inc. 43 Section 8
Section 8. The disputed claims process
Follow this Federal Employees Health Benefits Program disputed claims process if you disagree with our decision on
your claim or request for services, drugs, or supplies – including a request for preauthorization:

Step Description
Ask us in writing to reconsider our initial decision. You must:
(a) Write to us within 6 months from the date of our decision; and
(b) Send your request to us at: CapitalCare Inc, 550 12 th Street SW, Washington DC 20065; 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.

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.

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.

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. 43
43 Page 44 45
2001 CapitalCare, Inc. 44 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.

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.

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
800/ 680-9495 or 202/ 479-3708 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/ 606-0755 between 8 a. m. and 5 p. m. eastern time. 44
44 Page 45 46
2001 CapitalCare, Inc. 45 Section 9
Section 9. Coordinating benefits with other coverage
When you have other health coverage You must tell us if you are covered or a family member is covered under another group health plan or have automobile insurance that pays health
care expenses without regard to fault. This is called "double coverage."
When you have double coverage, one plan normally pays its benefits in
full as the primary payer and the other plan pays a reduced benefit as the
secondary payer. We, like other insurers, determine which coverage is
primary according to the National Association of Insurance
Commissioners' guidelines.

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

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

What is Medicare? Medicare is a Health Insurance Program for:

People 65 years of age and older.
Some people with disabilities, under 65 years of age.
People with End-Stage Renal Disease (permanent kidney failure requiring dialysis or a transplant).

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

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

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

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

We will not waive any of our copayments.
(Primary payer chart begins on next page.) 45
45 Page 46 47
2001 CapitalCare, Inc. 46 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………………………………………… …………………….. ……. 46
46 Page 47 48
2001 CapitalCare, Inc. 47 Section 9
Please note, if your Plan physician does not participate in Medicare, you will have to file a claim with Medicare.
You will be responsible for amounts not covered by Medicare, Plan copays and amounts over the Plan allowance.

Claims process --You probably will never have to file a claim form when you have both our Plan and Medicare.

When we are the primary payer, we process the claim first.
When Original Medicare is the primary payer, Medicare processes your claim first. In most cases, your claims will be
coordinated automatically. You will not need to do anything.
To find out if you need to do something about filing your
claims, call us at 800/ 680-9495.

We waive some costs when you have Medicare --When Medicare is the primary payer, we will waive some out-of-pocket costs, as follows:
In this case we do not waive any out-of-pocket cost.

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, specialist, or
hospitals that are part of the plan. Medicare managed care plans cover all
Medicare Part A and B benefits. Some cover extras, like prescription
drugs. To learn more about enrolling in a Medicare managed care plan,
contact Medicare at 1-800-MEDICARE (1-800-633-4227) or at
www. medicare. gov. If you enroll in a Medicare managed care plan, the
following options are available to you:

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

Suspended FEHB coverage and a Medicare managed care plan: If you are an annuitant or former spouse, you can suspend your FEHB
coverage to enroll in a Medicare managed care plan, eliminating your
FEHB premium. (OPM does not contribute to your Medicare managed
care plan premium.) For information on suspending your FEHB
enrollment, contact your retirement office. If you later want to re-enroll
in the FEHB Program, generally you may do so only at the next open
season unless you involuntarily lose coverage or move out of the
Medicare 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. 47
47 Page 48 49
2001 CapitalCare, Inc. 48 Section 9
TRICARE TRICARE is the health care program for members, eligible dependents of military persons and retirees of the military. TRICARE includes the
CHAMPUS program. If both TRICARE and this Plan cover you, we pay
first. See your TRICARE Health Benefits Advisor if you have questions
about TRICARE coverage.

Workers' Compensation We do not cover services that:
you need because of a workplace-related disease or injury that the Office of Workers' Compensation Programs (OWCP) or a similar
Federal or State agency determines they must provide; or

OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you
filed under OWCP or similar laws.
Once OWCP or similar agency pays its maximum benefits for your
treatment, we will cover your benefits. You must use our providers.

Medicaid When you have this Plan and Medicaid, we pay first.

When other Government agencies We do not cover services and supplies when a local, State, are responsible for your care or Federal Government agency directly or indirectly pays for them.
When others are responsible When you receive money to compensate you for for injuries medical or hospital care for injuries or illness caused by another person,
you must reimburse us for any expenses we paid. However, we will
cover the cost of treatment that exceeds the amount you received in the
settlement.

If you do not seek damages you must agree to let us try. This is called
subrogation. If you need more information, contact us for our
subrogation procedures. 48
48 Page 49 50
2001 CapitalCare, Inc. 49 Section 10
Section 10. Definitions of terms we use in this brochure
Calendar year January 1 through December 31 of the same year. For new enrollees, the calendar year begins on the effective date of their enrollment and ends on
December 31 of the same year.

Copayment A copayment is a fixed amount of money you pay when you receive covered services. See page 11.

Coinsurance Coinsurance is the percentage of our allowance that you must pay for your care. See page 11.
Covered services Care we provide benefits for, as described in this brochure.
Custodial care Treatment or services that could be rendered safely or reasonably by a person not medically skilled to provide such services.

Deductible A deductible is a fixed amount of covered expenses you must incur for certain covered services and supplies before we start paying benefits for
those services. See page 11.

Experimental or Investigational services Services legally used in testing or other studies on human patients Services recognized as safe and effective for the treatment of a
specific condition.
Services approved by any governmental authority whose approval is required.

Services approved for human use by the Federal Food and Drug Administration in the case a drug, therapeutic regimen, or device is
used.

Group health coverage Health coverage made available through employment or membership with a particular organization or group.

Medical necessity Services or supplies that: are proper and needed for the diagnosis or treatment of your medical
condition;
are provided for the diagnosis, direct care, and treatment of your medical condition;

meet the standards of good practice in the medical community of your local area; and,
are not mainly for the convenience for you or your doctor.

Us/ We Us and we refer to CapitalCare Inc.
You You refers to the enrollee and each covered family member. 49
49 Page 50 51
2001 CapitalCare, Inc. 50 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. 50
50 Page 51 52
2001 CapitalCare, Inc. 51 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. 51
51 Page 52 53
2001 CapitalCare, Inc. 52 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 800/ 680-9494
or 202/ 479-3708 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. 52
52 Page 53 54
2001 CapitalCare, Inc. 53 Index
Index
Do not rely on this page; it is for your convenience and does not explain your benefit coverage.
Accidental injury 39 Allergy tests 17
Alternative treatment 22 Ambulance 29
Anesthesia 26 Autologous bone marrow
transplant 26 Blood and blood plasma 28
Breast cancer screening 15 Casts 28
Catastrophic protection 55 Changes for 2001 7
Chemotherapy 18 Childbirth 16
Cholesterol tests 14 Claims 42
Coinsurance 11 Colorectal cancer screening 14
Congenital anomalies 23 Contraceptive devices and drugs 36
Coordination of benefits 45 Covered providers 8
Deductible 11 Definitions 49
Dental care 39 Diagnostic services 13
Disputed claims review 43 Donor expenses (transplants) 26
Dressings 28 Durable medical equipment
(DME) 21 Educational classes and programs 22
Effective date of enrollment 51 Emergency 30
Experimental or investigational 49 Eyeglasses 20
Family planning 16 Fecal occult blood test 14
General Exclusions 41

Hearing services 19 Home health services 21
Hospice care 29 Home nursing care 21
Hospital 27 Immunizations 15
Infertility 17 Inhospital physician care 23
Inpatient Hospital Benefits 27 Insulin 36
Laboratory and pathological services 14
Machine diagnostic tests 14 Magnetic Resonance Imagings
(MRIs) 14 Mail Order Prescription Drugs 36
Mammograms 15 Maternity Benefits 16
Medicaid 48 Medically necessary 49
Medicare 45 Members 50
Mental Conditions/ Substance Abuse Benefits 33
Newborn care 16 Non-FEHB Benefits 40
Nurse 21 Licensed Practical Nurse 21
Registered Nurse 21 Nursery charges 16
Obstetrical care 16 Occupational therapy 19
Ocular injury 20 Office visits 13
Oral and maxillofacial surgery 25 Orthopedic devices 21
Out-of-pocket expenses 11 Outpatient facility care 28
Oxygen 21

Pap test 14 Physical examination 15
Physical therapy 19 Physician 5
Precertification 10 Preventive care, adult 14
Preventive care, children 15 Prescription drugs 35
Preventive services 14 Prior approval 10
Prostate cancer screening 14 Prosthetic devices 21
Psychologist 33 Radiation therapy 18
Rehabilitation therapies 19
Renal dialysis 45 Room and board 27

Second surgical opinion 13 Skilled nursing facility care 29
Speech therapy 19 Splints 28
Sterilization procedures 16 Subrogation 48
Substance abuse 33 Surgery 23
Anesthesia 26 Oral 25
Outpatient 23 Reconstructive 24
Syringes 36 Temporary continuation of
coverage 51 Transplants 26
Treatment therapies 18
Vision services 20 Well child care 15

Workers' compensation 48 X-rays 14 53
53 Page 54 55
2001 CapitalCare, Inc. 54 Notes
Notes 54
54 Page 55 56
2001 CapitalCare, Inc. 63 Summary
Summary of benefits for CapitalCare -2001
Do not rely on this chart alone. All benefits are provided in full unless indicated and are subject to the
definitions, limitations, and exclusions in this brochure. On this page we summarize specific expenses we cover;
for more detail, look inside.

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

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

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

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

Nothing
$10 copay per visit

27

28
Emergency benefits:
In-area ..............................................................................................
Out-of-area .......................................................................................

$25 per emergency room visit
$25 per emergency room visit

32
32
Mental health and substance abuse treatment...................................... Regular cost sharing. 33
Prescription drugs.................................................................................. $8 generic copay; $15 formulary
brand copay; $30 copay for all
other

35

Dental Care........................................................................................ No benefit. 39
Vision Care........................................................................................ $10 per visit at participating
vision centers or $25 per visit at
participating ophthalmologists
(equires referral)

20

Special features: 24 hour nurse line 38
Protection against catastrophic costs
(your out-of-pocket maximum).........................................................

Nothing after $1,900/ Self Only or
$5,500/ Family enrollment per year

Some costs do not count toward
this protection

11 55
55 Page 56
2001 Rate Information for
CapitalCare, Inc.

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

The Washington, DC area
Self Only 2G1 $86.59 $32.42 $187.61 $70.25 $102.22 $16.79

Self and Family 2G2 $195.82 $77.90 $424.28 $168.78 $231.17 $42.55 56

Page Navigation Panel