CALL - THE HEALTH CARE FRAUD HOTLINE

202-418-3300

OR WRITE TO:

United States Office of Personnel Management

Office of the Inspector General Fraud Hotline

1900 E Street NW Room 6400

Washington, DC20415-1100

Identification cards

We will send you an identification (ID) card when you enroll. You should carry your ID card with you at all times. You must show it whenever you receive services from a Plan provider, or fill a prescription at a Plan pharmacy. Until you receive your ID card, use your copy of the Health Benefits Election Form, SF-2809, your health benefits enrollment confirmation (for annuitants), or your Employee Express confirmation letter.

If you do not receive your ID card within 30 days after the effective date of your enrollment, or if you need replacement cards, call us at 1-800-410-7778 or write to us at Mail Handlers Benefit Plan, P.O. Box 24503, Tucson, AZ 85734. You may also request replacement cards through our Web site: www.mhbp.com.

Where you get covered care

You can get care from any “covered provider” or “covered facility”. How much we pay – and you pay – depends on the type of covered provider or facility you use or who bills for the services. If you use PPO providers, you will pay less.

Covered providers

We consider the following to be covered providers when they perform covered services within the scope of their license or certification:

a licensed doctor of medicine (M.D.)

a licensed doctor of osteopathy (D.O.)

a licensed doctor of podiatry (D.P.M.)

a licensed dentist

a chiropractor (D.C.)

a licensed registered physical therapist (R.P.T.)

a licensed occupational therapist

a licensed speech therapist

a clinical psychologist

a clinical social worker

an optometrist

an audiologist

an acupuncturist

a physician’s assistant

a nurse midwife

a nurse practitioner/clinical specialist

a nursing school-administered clinic

a certified registered nurse anesthetist (C.R.N.A)

a Christian Science practitioner listed in the Christian Science Journal

a Christian Science nurse listed in the Christian Science Journal.

Medically underserved areas. Note: We cover any licensed medical practitioner for any covered service performed within the scope of that license in states OPM determines are “medically underserved”. For 2005, the states are: Alabama, Alaska, Idaho, Kentucky, Louisiana, Mississippi, Missouri, Montana, New Mexico, North Dakota, South Carolina, South Dakota, Texas, and Wyoming.

Covered facilities

Covered facilities include:

Freestanding ambulatory facility. A facility which meets the following criteria: has permanent facilities and equipment for the primary purpose of performing surgical and/or renal dialysis procedures on an outpatient basis; provides treatment by or under the supervision of doctors and nursing services whenever the patient is in the facility; does not provide inpatient accommodations; and is not, other than incidentally, a facility used as an office or clinic for the private practice of a doctor or other professional. The Plan will apply its outpatient surgical facility benefits only to facilities that have been accredited by the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) or the Accreditation Association for Ambulatory HealthCare (AAAHC), or that have Medicare certification as an ASC facility.

Managed In-Network providers. The Plan may approve coverage of providers who are not currently shown as Covered providers, to provide mental health/substance abuse treatment under the managed In-Network benefit. Coverage of these providers is limited to circumstances where the Plan has approved the treatment plan.

Hospital. An institution that is accredited as a hospital under the Hospital Accreditation Program of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), or any other institution that is operated pursuant to law, under the supervision of a staff of doctors (M.D. or D.O.) and with 24-hour-a-day nursing services, and that is primarily engaged in providing:

(a) general inpatient acute care and treatment of sick and injured persons through medical, diagnostic, and major surgical facilities, all of which facilities must be provided on its premises or under its control; or

(b) specialized inpatient acute medical care and treatment of sick or injured persons through medical and diagnostic facilities (including X-ray and laboratory) on its premises under its control, or through a written agreement with a hospital or with a specialized provider of those facilities; or

(c) a licensed birthing center.

In no event shall the term “hospital” include any part of a hospital that provides long-term care or sub-acute care, rather than acute care, or a convalescent nursing home, or any institution or part thereof that:

(a) is used principally as a convalescent facility, rest facility, nursing facility, or facility for the aged; or

(b) furnishes primarily domiciliary or custodial care, including training in the routines of daily living; or

(c) is operated as a school; or

(d) is operated as a residential treatment facility regardless of its State licensure or accreditation status.

Christian Science nursing facility. A facility which is approved by the Commission for the Accreditation of Christian Science Nursing Organizations/Facilities, Inc.

Hospice. A facility that:

(a) provides primarily inpatient care to terminally ill patients;

(b) is licensed/certified by the jurisdiction in which it operates;

(c) is supervised by a staff of doctors (M.D. or D.O.) with at least one such doctor on call 24 hours a day;

(d) provides 24-hour-a-day nursing services under the direction of a registered nurse (R.N.) and has a full-time administrator; and

(e) provides an ongoing quality assurance program.

What you must do to get covered care

It depends on the kind of care you want to receive. You can go to any provider you want, but we must approve some care in advance.

Transitional care

Specialty care: If you have a chronic or disabling condition and

lose access to your specialist because we drop out of the Federal Employees Health Benefits (FEHB) Program and you enroll in another FEHB Plan, or

lose access to your PPO specialist because we terminate our contract with your specialist for other than for cause,

you may be able to continue seeing your specialist and receiving any PPO benefits 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 and any PPO benefits continue until the end of your postpartum care, even if it is beyond the 90 days.

Hospital care

We pay for covered services from the effective date of your enrollment. However, if you are in the hospital when your enrollment in our Plan begins, call our customer service department immediately at 1-800-410-7778.

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 hospitalized person. If your plan terminates participation in the FEHB in whole or in part, or if OPM orders an enrollment change, this continuation of coverage provision does not apply. In such case, the hospitalized family member’s benefits under the new plan begin on the effective date of enrollment.

How to get approval for…

Your hospital stay

Precertification is the process by which – prior to your inpatient hospital admission – we evaluate the medical necessity of your proposed stay and the number of days required to treat your condition. Unless we are misled by the information given to us, we won’t change our decision on medical necessity.

In most cases, your physician or hospital will take care of precertification. Because you are still responsible for ensuring that we are asked to precertify your care, you should always ask your physician or hospital whether they have contacted us.

Warning:

We will reduce our benefits for the inpatient hospital stay by $500 if no one contacts us for precertification. If the stay is not medically necessary, we will not pay any benefits.

Any stay greater than 23 hours must be precertified.

How to precertify an admission

You, your representative, your doctor, or your hospital must call us at 1-800-410-7778 at least two working days before admission. The toll-free number is 1-800-410-7778.

If you have an emergency admission due to a condition that you reasonably believe puts your life in danger or could cause serious damage to bodily function, you, your representative, the doctor, or the hospital must telephone us within two business days following the day of the emergency admission, even if you have been discharged from the hospital.

Provide the following information:

Enrollee’s name and Plan identification number;

Patient’s name, birth date, and phone number;

Reason for hospitalization, proposed treatment, or surgery;

Name of hospital or facility; and

Name and phone number of admitting doctor; and

Number of planned days of confinement.

We will then tell the doctor and/or hospital the number of approved days of confinement for the care of the patient’s condition. Written confirmation of the Plan’s certification decision will be sent to you, your doctor, and the hospital. If the length of stay needs to be extended, follow the procedures below.

Maternity care

You do not need to precertify a maternity admission for a routine delivery. However, if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section, then your physician or the hospital must contact us for precertification of additional days. Further, if your baby stays after you are discharged, then you, your representative, your physician or the hospital must contact us for precertification of additional days for your baby.

If your hospital stay needs to be extended:

If your hospital stay – including for maternity care – needs to be extended, you, your representative, your doctor or the hospital must ask us to approve the additional days.

What happens when you do not follow the precertification rules

If no one contacted us, we will decide whether the hospital stay was medically necessary.

If we determine that the stay was medically necessary, we will pay the inpatient charges, less the $500 penalty.

If we determine that it was not medically necessary for you to be an inpatient, we will not pay inpatient hospital benefits. We will pay 70% for covered medical supplies and services that are otherwise payable on an outpatient basis.

If we denied the precertification request, we will not pay room and board inpatient hospital benefits. We will pay 70% for covered medical supplies and services that are otherwise payable on an outpatient basis.

If you remain in the hospital beyond the number of days we approved and you do not get the additional days precertified, then:

we will pay inpatient benefits for the part of the admission that we determined was medically necessary, but

we will pay 70% of the covered medical services and supplies otherwise payable on an outpatient basis and will not pay room and board benefits for the part of the admission that was not medically necessary.

Exceptions:

You do not need precertification in these cases:

You are admitted to a hospital outside the United States.

You have another group health insurance policy that is the primary payer for the hospital stay.

Your Medicare Part A is the primary payer for the hospital stay. Note: If you exhaust your Medicare hospital benefits and do not want to use your Medicare lifetime reserve days, then we will become the primary payer and you do need precertification

Your stay is less than 23 hours.

Other services

Some services require precertification or preauthorization.

We require preauthorization of mental health/substance abuse services under the managed In-Network benefit for High Option and Standard Option.
See Section 5(e).

We require preauthorization of certain classes of drugs.
See Sections 5(f) and 6(d).

We require preauthorization of transplant services under the National Transplant Program. You or your physician must call 1-800-410-7778 to speak with a transplant case manager prior to your pre-transplant evaluation as a potential candidate for a transplant procedure. See Section 5(b) and 6(c).

We require precertification when Medicare Part B is the primary payer and an outpatient hospitalization exceeds 23-hours or results in hospital admission.

You should call us at 1-800-410-7778 before scheduling any outpatient procedures; we can help you locate a PPO facility.

Copayments

A copayment is a fixed amount of money you pay to the provider, facility, pharmacy, etc., when you receive services.

Example: When you have High or Standard Option and see your PPO physician you pay a copayment of $20 per visit for adult members or $10 per visit for dependent children under age 22.

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 them. Copayments and coinsurance do not count toward any deductible.

High Option and Standard Option

The High Option calendar year deductible for covered medical services and supplies is $250 per person ($750 per family) for services received from PPO providers, and $300 per person ($900 per family) for services received from non-PPO providers. The Standard Option calendar year deductible for covered medical services and supplies is $300 per person ($600 per family) for services received from PPO providers, and $350 per person ($900 per family) for services received from non-PPO providers. Whether or not you use PPO providers, your deductible will not exceed the applicable non-PPO amounts. Under a family enrollment, the medical services and supplies deductible is satisfied for all family members when the combined covered expenses applied to the calendar year deductible for all family members reach the respective per family limit.

If you were continuously enrolled in the Plan for the entire prior year and did not meet the calendar year deductible for medical services and supplies for that year (based on claims received by the Plan by December 31 of that year), we will waive $125 per person (up to $375 per family) of that deductible for the current year if you are enrolled in the High Option, or $150 per person (up to $450 per family) of that deductible if you are enrolled in the Standard Option. Example 1: If family member A incurs only $249 of the $250 High Option deductible for 2004, we will waive $125 of the deductible for 2005. Example 2: If three family members each incur only $299 of the $300 Standard Option deductible for 2004, we will waive $150 of the deductible for 2005 for each of these family members. This waiver does not apply to any other deductible under this Plan. This deductible waiver will apply even if you change options of the Plan in the current year. If you change options in this Plan during Open Season, the waiver amount will be based on your new option. This waiver is available only for High Option and Standard Option.

The calendar year deductible for covered mental health/substance abuse services under High Option is $250 per person, limited to $750 per family, for services received from managed in-network providers and $300 per person, limited to $900 per family, for services received from non-network providers. The calendar year deductible for covered mental health/substance abuse services under Standard Option is $300 per person, limited to $600 per family, for services received from managed in-network providers and $350 per person, limited to $900 per family, for services received from non-network providers. Whether or not you use PPO providers, your deductible will not exceed the applicable non-PPO amounts. This deductible is in addition to the medical services deductible. Under a family enrollment, the mental health/substance abuse services deductible is satisfied for all family members when the combined covered expenses applied to the calendar year deductible reach the respective per family limit.

The calendar year deductible for prescription drugs is $200 per person under High Option and $350 per person under Standard Option. Under a family enrollment, this deductible is met when the family has incurred $400 under High Option and $700 under Standard Option. The prescription drug deductible does not apply to generic drugs. The prescription drug deductible is waived for members who have Medicare Parts A and B as their primary coverage.

Deductible (continued)

Note: If you change plans or plan options during Open Season, you do not have to start a new deductible under your old plan or plan option between January 1 and the effective date of your new plan or plan option. And, if you change options in this Plan during the year, we will credit the amount of covered expenses already applied toward the deductible of your old option to the deductible of your new option.

If you change plans during the year, you must begin a new deductible under your new plan.

In 2005, we are introducing a new Consumer Option. Under the Consumer Option, you will have a Health Savings Account (HSA) if you are eligible or a Health Reimbursement Arrangement (HRA). An HSA is an account which you own. An HRA is a credit account which is used to pay for qualified out-of-pocket expenses. Due to Federal income tax rules, different cost sharing requirements apply to these options as explained below. For more information on the Consumer Option see Section 6.

Consumer Option (HSA):

The calendar year deductible for covered medical services and supplies, mental health/ substance abuse services, and prescription drugs, is $2,250 for a Self Only enrollment and $4,500 for a Self and Family enrollment.

Consumer Option (HRA):

The calendar year deductible for covered medical services and supplies, mental health/substance abuse services, and prescription drugs, is $2,250 for a Self Only enrollment and $4,500 for a Self and Family enrollment. This includes your HRA credit amount and your Member Responsibility.

Coinsurance

High Option And Standard Option

Coinsurance is the percentage of our allowance that you must pay for your care. Coinsurance doesn’t begin until you meet your deductible.

Example: You pay 30% of our allowance for non-PPO office visits.

Consumer Option (HSA or HRA)

Coinsurance is the percentage of our allowance that you must pay under Traditional Health Coverage. Coinsurance does not begin until you meet your deductible (HSA) or your Member Responsibility (HRA).

Example: You pay 40% of our allowance for non-PPO office visits.

Note: If your provider routinely waives (does not require you to pay) your copayments, deductibles, or coinsurance, the provider is misstating the fee and may be violating the law. In this case, when we calculate our share, we will reduce the provider’s fee by the amount waived.

For example, if your physician ordinarily charges $100 for a covered service but routinely waives your 30% coinsurance (High Option or Standard Option), the actual charge is $70. We will pay $49 (70% of the actual charge of $70).

To help keep your coinsurance out-of-pocket costs to a minimum, we encourage you to call us at1-800-410-7778 or visit our Web site at www.mhbp.com for assistance locating PPO providers whenever possible.

Member Responsibility

Consumer Option (HRA Only):

Your Member Responsibility is your bridge between your Health Reimbursement Arrangement (HRA) and your Traditional Health Coverage. After you have exhausted your HRA credit, you must pay your Member Responsibility before your Traditional Health Coverage begins. Your Member Responsibility is $1,250 for a Self Only enrollment or $2,500 for a Self and Family enrollment.

Differences between our allowance and the bill

High Option and Standard Option: Our “Plan allowance” is the amount we use to calculate our payment for covered services. Fee-for-service plans arrive at their allowances in different ways, so their allowances vary. For more information about how we determine our Plan allowance, see the definition of Plan allowance in Section 12.

Often, the provider’s bill is more than a fee-for-service plan’s allowance. Whether or not you have to pay the difference between our allowance and the bill will depend on the provider you use.

PPO providers agree to limit what they will bill you. Because of that, when you use a preferred provider, your share of covered charges consists only of your deductible and coinsurance or copayment. Here is an example: You see a PPO physician for an office visit who charges $150, but our allowance is $100. You are only responsible for your coinsurance. That is, you pay just $20 of our $100 allowance for an adult office visit. Because of the agreement, your PPO physician will not bill you for the $50 difference between our allowance and his bill.

Non-PPO providers, on the other hand, have no agreement to limit what they will bill you. When you use a non-PPO provider, you will pay your deductible and coinsurance – plus any difference between our allowance and charges on the bill. Here is an example: You see a non-PPO physician who charges $150 and our allowance is again $100. Because you’ve met your deductible, you are responsible for your coinsurance, so you pay 30% of our $100 allowance ($30). Plus, because there is no agreement between the non-PPO physician and us, he can bill you for the $50 difference between our allowance and his bill. For details on how we determine the Plan allowance, please see Section 12.

MultiPlan providers agree to limit what they can collect from you. You will still have to pay your deductible and coinsurance. These providers agree to write off the difference between billed charges and the discount amount.

The following table illustrates the examples of how much you have to pay out-of-pocket for services from a PPO physician vs. a non-PPO physician. The table uses our example of a service for which the physician charges $150 and our allowance is $100. The table shows the amount you pay under High Option if you have met your calendar year deductible.

Physician’s charge

$150

$150

Our allowance

We set it at: $100

We set it at: $100

We pay

$80

70% of our allowance: $70

You owe: Copayment

$20

30% of our allowance: $30

+Difference up to charge?

No: $0

Yes: $50

TOTAL YOU PAY

$20

$80

Differences between our allowance and the bill (continued)

Consumer Option:

PPO providers agree to accept our Plan allowance so if you use a PPO Provider, you never have to worry about paying the difference between the Plan’s allowance and the billed amount for covered services.

Non-PPO Providers: If you use a non-PPO provider, you will have to pay the difference between the Plan allowance and the billed amount. After you have exhausted your HSA or HRA, you will be responsible for paying your remaining deductible and also copayments and coinsurance under the Traditional Health Coverage

Note: We encourage you to use PPO providers because it will make the amounts in your HSA or HRA last longer.

Your catastrophic protection out-of-pocket maximum for coinsurance

High Option and Standard Option:

For those services with coinsurance (excluding mental health and substance abuse care), we pay 100% of the Plan allowance for the remainder of the calendar year after your coinsurance expenses total these amounts:

$4,500 for services of PPO providers/facilities under the High and Standard Options

$9,000 for services of PPO and non-PPO providers/facilities, combined, under the High and Standard Options.

For mental health and substance abuse benefits, we pay 100% of the Plan allowance for the remainder of the calendar year after your coinsurance expenses total:

$4,500 for services of In-network providers/facilities under the High and Standard Options.

Note: Your out-of-pocket maximum does not apply to these benefits and you must continue to pay applicable copayments and coinsurance for these expenses:

Skilled nursing care

Prescriptions drugs

Any out-of-network mental health and substance abuse care

Hospice

Dental services

Rehabilitative and alternative therapies

Note: The following cannot be counted toward out-of-pocket expenses:

Deductibles

Copayments

Expenses incurred under Prescription Drug Benefits

Expenses in excess of the Plan allowance or maximum benefit limitations

Any out-of-network expenses for mental health and substance abuse care

Amounts you pay for non-compliance with this Plan’s cost containment requirements

Coinsurance for skilled nursing care

Non-covered services and supplies

Coinsurance for alternative and rehabilitative therapy

Your catastrophic protection out-of-pocket maximum for coinsurance (continued)

Consumer Option:

PPO benefit: Your catastrophic out-of-pocket maximum is $5,000 per person ($10,000 per family) when you use PPO providers/facilities and pharmacies. Only eligible expenses for network providers count toward this limit.

Out of pocket expenses for purposes of this benefit are:

Your annual deductible and the in-network copayments that you pay under the Traditional Health Coverage

The following cannot be included in the accumulation of out-of-pocket expenses:

Expenses in excess of the Plan’s allowance, or maximum benefit limitations or expenses not covered under the Traditional Health Coverage

Any amounts you pay because benefits have been reduced for non-compliance with this Plan’s cost containment requirements (see pages 14-16)

Non-PPO benefit: Your catastrophic out-of-pocket maximum is $7,500 per person ($15,000 per family) when you use non-PPO providers/facilities. Eligible expenses for network providers also count toward this limit. Your eligible out-of-pocket expenses will not exceed this amount whether or not you use network providers

Out of pocket expenses for purposes of this benefit are:

The copayments you pay for in-network inpatient and outpatient hospital charges, surgical, medical, maternity and emergency services under the Traditional Health Coverage

Your annual deductible and the 40% you pay for out-of-network inpatient and outpatient hospital charges, surgical, medical, maternity and emergency services under the Traditional Health Coverage

The following cannot be included in the accumulation of out-of-pocket expenses:

Expenses in excess of the Plan’s allowance, or maximum benefit limitations or expenses not covered under the Traditional Health Coverage

Expenses for out-of-network mental health or substance abuse care

Amounts you pay for non-compliance with this Plan’s cost containment requirements

Coinsurance for skilled nursing care

Coinsurance for alternative and rehabilitative therapy

Carryover

If you changed to this Plan during open season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1, any expenses that would have applied to that plan’s catastrophic protection benefit during the prior year will be covered by your old plan if they are for care you received in January before your effective date of coverage in this Plan. If you have already met your old plan’s catastrophic protection benefit level in full, it will continue to apply until the effective date of your coverage in this Plan. If you have not met this expense level in full, your old plan will first apply your covered out-of-pocket expenses until the prior year’s catastrophic level is reached and then apply the catastrophic protection benefit to covered out-of-pocket expenses incurred from that point until the effective date of your coverage in this Plan. Your old plan will pay these covered expenses according to this year’s benefits; benefit changes are effective January 1.

Note: If you change options in this Plan during the year, we will credit the amount of covered expenses already accumulated toward the catastrophic out-of-pocket limit of your old option to the catastrophic protection limit of your new option.

When Government facilities bill us

Facilities of the Department of Veteran Affairs, the Department of Defense, and the Indian Health Service are entitled to seek reimbursement from us for certain services and supplies they provide to you or a family member. They may not seek more than their governing laws allow.

If we overpay you

We will make diligent efforts to recover benefit payments we made in error but in good faith. We may reduce subsequent benefit payments to offset overpayments.

When you are age 65 or over and do not have Medicare

Under the FEHB law, we must limit our payments for inpatient hospital care and physician care to those benefits you would be entitled to if you had Medicare. And, your physician and hospital must follow Medicare rules and cannot bill you for more than they could bill you if you had Medicare. You and the FEHB benefit from these payment limits. Outpatient hospital and non-physician based care is not covered by this law; regular Plan benefits apply. The following chart has more information about the limits.

If you…

are age 65 or over, and

do not have Medicare Part A, Part B, or both; and

have this Plan as an annuitant or as a former spouse, or as a family member of an annuitant or former spouse; and

are not employed in a position that gives FEHB coverage. (Your employing office can tell you if this applies.)

Then, for your inpatient hospital care,

the law requires us to base our payment on an amount - the "equivalent Medicare amount" - set by Medicare’s rules for what Medicare would pay, not on the actual charge;

you are responsible for your applicable deductibles, coinsurance, or copayments you owe under this Plan;

you are not responsible for any charges greater than the equivalent Medicare amount; we will show that amount on the explanation of benefits (EOB) form that we send you; and

the law prohibits a hospital from collecting more than the Medicare equivalent amount.

And, for your physician care, the law requires us to base our payment and your coinsurance on…

an amount set by Medicare and called the "Medicare approved amount," or

the actual charge if it is lower than the Medicare approved amount.

If your physician…

Then you are responsible for…

Participates with Medicare or accepts Medicare assignment for the claim and is a member of our PPO network,

your deductibles, coinsurance, and copayments;

Participates with Medicare and is not in our PPO network,

your deductibles, coinsurance, copayments,
and any balance up to the Medicare approved
amount;

Does not participate with Medicare,

your deductibles, coinsurance, copayments,
and any balance up to 115% of the Medicare
approved amount

It is generally to your financial advantage to use a physician who participates with Medicare. Such physicians are permitted to collect only up to the Medicare approved amount.

Our explanation of benefits (EOB) form will tell you how much the physician or hospital can collect from you. If your physician or hospital tries to collect more than allowed by law, ask the physician or hospital to reduce the charges. If you have paid more than allowed, ask for a refund. If you need further assistance, call us at 1-800-410-7778.

When you have the Original Medicare Plan (Part A, Part B, or both)

High Option And Standard Option

We limit our payment to an amount that supplements the benefits that Medicare would pay under Medicare Part A (Hospital insurance) and Medicare Part B (Medical insurance), regardless of whether Medicare pays. Note: We pay our regular benefits for emergency services to an institutional provider, such as a hospital, that does not participate with Medicare and is not reimbursed by Medicare.

If you are covered by Medicare Part B and it is primary, your out-of-pocket costs for services that both Medicare Part B and we cover depend on whether your physician accepts Medicare assignment for the claim.

When Medicare is primary, all or part of your Plan deductibles, copayments and coinsurance will be waived as indicated below:

When Medicare Part A is primary, the Plan will waive applicable per-admission copayments and coinsurance for inpatient hospital benefits, inpatient mental health/substance abuse benefits and nursing benefits.

When Medicare Part B is primary, the Plan will waive applicable deductibles, copayments and coinsurance for surgical and medical services billed by physicians, durable medical equipment, orthopedic and prosthetic appliances, ambulance services and outpatient mental health/substance abuse services.

When Medicare Parts A and B are primary, the plan will waive the calendar year deductible for prescription drugs purchased at a retail pharmacy and through the mail order prescription drug program for both High Option and Standard Option.

Note: The plan will not waive the copayment and coinsurance for retail or mail order prescription drugs.

It is important to know that a physician who does not accept Medicare assignment may not bill you for more than 115% of the amount Medicare bases its payment on, called the “limiting charge.” The Medicare Summary Notice (MSN) that Medicare will send you will have more information about the limiting charge. If your physician tries to collect more than allowed by law, ask the physician to reduce the charges. If the physician does not, report the physician to your Medicare carrier who sent you the MSN form. Call us if you need further assistance.

Please see Section 11, Coordinating benefits with other coverage, for more information about how we coordinate benefits with Medicare.

Consumer Option (HRA):

If your physician accepts Medicare assignment, then you pay nothing if you have unused credit available under your HRA to pay the difference between the Medicare approved amount and Medicare’s payment. After your HRA is exhausted and your Member Responsibility has been met, you pay either the difference between the Medicare approved amount and Medicare’s payment or your copayment amount, whichever is less.

Note: The Plan will not waive any deductibles, copayments or coinsurance when you have Medicare Part A and/or B as your primary payer.

I

M

P

O

R

T

A

N

T

Here are some important things you should 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.

The calendar year deductible is: $300 per person ($600 per family) for Standard Option PPO services and $350 per person ($900 per family) for Standard Option non-PPO services; and $250 per person ($750 per family) for High Option PPO services and $300 per person ($900 per family) for High Option non-PPO services. The calendar year deductible applies to almost all benefits in this Section. We added “(No deductible)” to show when the calendar year deductible does not apply. See Section 4 for more information about deductibles (including the deductible waiver) and other cost-sharing features such as coinsurance and copayments.

The non-PPO benefits are the standard benefits of this Plan. PPO benefits apply only when you use a provider participating in the First Health® Network. When no PPO provider is available, non-PPO benefits apply.

Be sure to read Section 4, Your costs for covered services, for valuable information about how cost sharing works, with special sections for members who are age 65 or over. Also read Section 11 about coordinating benefits with other coverage, including with Medicare.

I

M

P

O

R

T

A

N

T

Note: The calendar year deductible applies to almost all benefits in this Section. We say "(No deductible)" when it does not apply.