U.S. Office of Personnel Management - Ensuring the Federal Government has an effective civilian workforce

This is a general description of the plan changes. This page is not an official statement of benefits. For that, go to the Benefits descriptions in the Plan Brochure. Also, we edited and clarified language throughout the brochure; any language change not shown here is a clarification that does not change benefits.

• Your share of the non-Postal High Option Self Only premium will increase by 48.7%. For High Option Self and Family your share will increase by 55%.

• Your share of the non-Postal Standard Option Self Only premium will increase by 14.5%. For Standard Option Self and Family your share will increase by 14.5%.

• The Plan will have a separate calendar year deductible for PPO and non-PPO services under each option. The deductibles will be: $250 per person ($750 per family) for PPO services and $300 per person ($900 per family) for non-PPO services under High Option and $300 per person ($750 per family) for PPO services and $350 per person ($900 per family) for non-PPO services under Standard Option. The calendar year deductible changes apply to both medical services and supplies and treatment of mental health and substance abuse. Previously, the High Option calendar year deductible was $250 per person ($750 per family) and the Standard Option calendar year deductible was $300 per person ($900 per family).

• We will introduce a calendar year deductible waiver provision for medical services and supplies beginning in 2004. If you were a Plan member throughout 2003 but did not meet the calendar year deductible for 2003, we will waive $125 per person (up to $375 per family) of the 2004 calendar year deductible under High Option. For Standard Option, we will waive $150 per person (up to $450 per family) of the 2004 calendar year deductible. You must submit these 2003 medical expenses to the Plan for application to the deductible no later than December 31, 2003.

• We changed our reimbursement level for inpatient hospital expenses. For PPO hospitals under both options, room and board expenses will continue to be paid at 100% of covered charges; hospital ancillary expenses will now be paid at 85% of covered charges. The PPO copayment per admission will be $100 for High Option and $200 for Standard Option. For non-PPO hospitals under both options, all covered charges will be paid at 70%. The non-PPO copayment per admission will be $300 for High Option and $400 for Standard Option. Previously, under both options all covered charges were paid at 100% for both PPO and non-PPO hospitals. The copayments per admission under High Option were: nothing for a PPO hospital and $250 for a non-PPO hospital. Under Standard Option, the copayments were: $150 per admission for a PPO hospital and $300 per admission for a non-PPO hospital.

• There will be separate PPO office visit copayments for adult visits and visits for dependent children. The copayment for adults will be increased to $20 per office visit and the copayment for dependent children under age 22 will be reduced to $10 per office visit. This PPO office visit copayment change applies to both options. Previously, the PPO office visit copayment for both adults and children was $15 under High Option and $18 under Standard Option.

• The calendar year prescription drug deductible will be reduced to $400 per person ($800 per family) under Standard Option. Previously, it was $600 per person ($1,200 per family).

• The calendar year prescription drug deductible will be reduced to $200 per person ($400 per family) under High Option. Previously, it was $250 per person ($500 per family).

• Generic drugs purchased at either a network retail pharmacy or by mail order will not be subject to the prescription drug deductible under either option.

• The copayments for network retail pharmacy prescription drugs under High Option will be: $10 per generic drug, $25 per preferred brand name drug, and $40 per non-preferred brand name drug. Previously, the copayments were: $7 per generic drug, $23 per preferred brand name drug, and $35 per non-preferred brand name drug.

• The copayments for network retail pharmacy prescription drugs under Standard Option will be: $10 per generic drug, $30 per preferred brand name drug, and $45 per non-preferred brand name drug. Previously, the copayments were: $8 per generic drug, $28 per preferred brand name drug, and $40 per non-preferred brand name drug.

• The catastrophic protection limit for PPO services will increase from $3,000 to $4,500 under High Option and from $4,000 to $4,500 under Standard Option.

• The catastrophic protection limit for any combination of PPO and non-PPO services will increase from $6,000 to $9,000 under High Option and from $6,500 to $9,000 under Standard Option.

• We added coverage for one osteoporosis screening (bone density study) every two years for members age 65 and over.

• Covered services provided by a chiropractor (D.C.) will not be subject to the calendar year deductible under either option.

• Outpatient facility expenses related to surgery will be paid at 90% for PPO services and 70% for non-PPO services under both options. These expenses will be subject to the calendar year deductible. Previously, PPO services were paid in full after the calendar year deductible was met.

• Outpatient hospital charges will now be subject to the "blended rate" allowance (see definition page 76). Please contact us to locate a PPO hospital. Your out-of-pocket expenses will increase if you do not use a PPO hospital when one is available to you.

• For Medicare beneficiaries covered under both Parts A and B of Medicare, we will waive the full prescription drug deductible under Standard Option for prescription drugs purchased at a retail pharmacy. Previously, only half of the prescription drug deductible was waived.

• Overseas providers (those outside the continental United States, Alaska and Hawaii) will be paid at the PPO level of benefits for covered services.

• The address for filing claims for Prescription Drug benefits has changed, see Section 7.

• We have clarified that vitamins, nutrients and food supplements are not covered unless, by law, a physician's prescription is required for dispensing them (see Section 5(f)).

• We have clarified that our benefits for specialty durable medical equipment items and prosthetic devices are limited to the cost of the standard item.

• We have clarified that our benefit for rental of durable medical equipment items is limited to the amount we would have paid as the secondary payer for the purchase of the equipment if you have other insurance coverage which pays benefits first.