CALL ¾ 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 800-341-6613. You may also request replacement cards through our Web site at www.chclouisiana.com

Where you get covered care

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

Plan providers

Plan providers are physicians and other health care professionals in our service area that we contract with to provide covered services to our members. We credential Plan providers according to national standards.

We list Plan providers in the provider directory, which we update periodically. The list is also on our Web site.

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 Web site.

What you must do to get covered care

It depends on the type of care you need.

Primary care

Coventry does not require you to select a primary care physician.

Specialty care

You may see a Specialist in the network without a referral.

Here are some other things you should know about specialty care:

If you have a chronic and 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 program 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 800-341-6613. 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. If your plan terminates participation in the FEHB Program 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.

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

For certain services 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 prior authorization. Your physician must obtain prior authorization.

Your physician must get the Plan's approval before sending you to a hospital, or recommended follow-up care. Before giving approval, we consider if the service is medically necessary, and if it follows generally accepted medical practice.

If you obtain services from a specialist, hospital or other health care provider, the services will be covered only if medically necessary and authorized, except in the case of emergency medical services and urgent care. Certain services, such as, but limited to inpatient hospital services, outpatient surgeries/treatments, skilled nursing facilities, home health services, durable medical equipment, certain diagnostic tests and subacute care also require approval of the utilization review department before the services are initiated.

Copayments

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

High Option: Example: when you see your physician you pay a $15 copayment per office visit.

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 do not count toward any deductible.

High Option: We have no plan deductible.

High Deductible Health Plan:

In Network - The calendar year deductible amount for this plan is $1,050 for individual coverage (subscribers covering no spouse or dependents) and $2,100 for family coverage (subscribers covering spouse and/or family).

Out of Network - The calendar year deductible amount for this plan is $2,000 for individual coverage (subscribers covering no spouse or dependents) and $4,000 for family coverage (subscribers covering spouse and/or family).

No benefit is payable for Covered Services subject to a Deductible, until the Deductible is met. You are responsible for paying Your Deductible. The individual Deductible is a limit on the amount You must pay before you receive benefits. The family Deductible is the limit on the total amount Members of the same family covered under this Agreement must pay before receiving benefits.

Note: If you change plans during Open Season, you do not have to start a new deductible under your old plan between January 1 and the effective date of your new plan. If you change plans at another time during the year, you must begin a new deductible under your new plan.

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.

Coinsurance

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

High Option: Example: you pay 50% of our allowance for infertility and allergy testing.

High Deductible Health Plan:

Example: In network - you pay 20% of our allowance for durable medical equipment after you have met the deductible. Out of network - you pay 30% of our allowance for durable medical equipment after you have met the deductible.

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 service but routinely waives your 15% coinsurance, the actual charge is $70. We will pay $59.50 (85% of the actual charge of $70).

Your catastrophic protection out-of-pocket maximum

High Option: After your coinsurance totals $1,000 per person or $3,000 per family enrollment in any calendar year, you do not have to pay any more for covered services. The calendar year out-of-pocket maximum does not include any copayments. In addition, coinsurance for the following services do not count toward your catastrophic protection out-of-pocket maximum, and you must continue to pay coinsurance for these services:

Certain Outpatient Facility Services

Infertility treatment

Be sure to keep accurate records of your copayments and coinsurance since you are responsible for informing us when you reach the maximum.

High Deductible Health Plan:

In Network - Your out-of pocket maximum for this plan is $4,000 per individual and $8,000 per family.

Out of Network - Your out-of pocket maximum for this plan is $6,000 per individual and $12,000 per family.

The individual Out-of-Pocket Maximum is a limit on the amount You must pay out of Your pocket for specific Covered Services in a calendar year. The family Out-of-Pocket Maximum is the limit on the total amount Members of the same family must pay for specific Covered Services in a calendar year. Once the Out-of-Pocket Maximum is met, Covered Services are paid at 100% for the remainder of the calendar year.

The out of pocket maximum includes all deductibles and coinsurance as applied by this plan.

Differences between our allowance and the bill

In-network providersagree to limit what they will bill you. Because of that, when you use a network provider, your share of covered charges consists only of your deductible and coinsurance or copayment. Here is an example about coinsurance: You see a network physician who charges $150, but our allowance is $100. If you have met your deductible, you are only responsible for your coinsurance. That is, you pay just - 15% of our $100 allowance ($15). Because of the agreement, your network physician will not bill you for the $50 difference between our allowance and his bill.

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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.

Plan physicians must provide or arrange your care.

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

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Professional services of physicians

In physician's office

$15 per office visit

Professional services of physicians

In an urgent care center

Office medical consultations

Second surgical opinion

$15 per office visit

At home

$25 per visit

Tests, such as:

Blood tests

Urinalysis

Non-routine pap tests

Pathology

X-rays

Non-routine Mammograms

CAT Scans/MRI

Ultrasound

Electrocardiogram and EEG

Nothing

Routine screenings, such as:

Total Blood Cholesterol

Colorectal Cancer Screening, including

- Fecal occult blood test

- Sigmoidoscopy, screening - every five years starting at age 50

- Double contrast barium enema - every five years starting at age 50

- Colonoscopy screening - every ten years starting at age 50

$15 per office visit

Routine Prostate Specific Antigen (PSA) test - one annually for men age 40 and older

$15 per office visit

Preventive care, adult - continued on next page

Routine pap test

Note: The office visit is covered if pap test is received on the same day; see Diagnosis and Treatment, above.

$15 per office visit

Routine mammogram - covered for women age 35 and older, as follows:

From age 35 through 39, one during this five year period

From age 40 through 64, one every calendar year

At age 65 and older, one every two consecutive calendar years

$15 per office visit

Routine immunizations, limited to:

Tetanus-diphtheria (Td) booster - once every 10 years, ages19 and over (except as provided for under Childhood immunizations)

Influenza vaccine, annually

Pneumococcal vaccine, age 65 and older

$15 per office visit

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

All charges.

Childhood immunizations recommended by the American Academy of Pediatrics

$15 per office visit

Well-child care charges for routine examinations, immunizations and care (up to age 22)

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 (up to age 22)

$15 per office visit

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 13 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).

$15 per office visit

Not covered: Routine sonograms to determine fetal age, size or sex.

All charges.

A range of voluntary family planning services, limited to:

Surgically implanted contraceptives (such as Norplant)

Injectable contraceptive drugs (such as Depo provera)

Diaphragm (fitting only)

Note: We cover oral contraceptives under the prescription drug benefit.

$15 per office visit

Voluntary sterilization (vasectomy or tubal ligation)

$100 per procedure

Not covered:

Reversal of voluntary surgical sterilization

Genetic counseling.

Intrauterine Devices (IUDs).

All charges.

Diagnosis and treatment of infertility such as:

Artificial insemination:

- intravaginal insemination (IVI)

- intracervical insemination (ICI)

- intrauterine insemination (IUI)

50% of charges

Not covered:

Assisted reproductive technology (ART) procedures, such as:

- in vitro fertilization

- embryo transfer, gamete intra-fallopian transfer (GIFT) and zygote intra-fallopian transfer (ZIFT)

Services and supplies related to ART procedures

Cost of donor sperm

Cost of donor egg

Fertility drugs

All charges.

Testing

Allergy injections and treatments

50% of charges

$15 per office visit

Allergy serum

Nothing

Not covered: Provocative food testing and sublingual allergy desensitization

All charges.

Chemotherapy and radiation therapy

Note: High dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed under Organ/Tissue Transplants on page 30.

Respiratory and inhalation therapy

Dialysis - hemodialysis and peritoneal dialysis

Intravenous (IV)/Infusion Therapy - Home IV and antibiotic therapy

Oxygen for home use and equipment

Growth hormone therapy (GHT)

Note: Growth hormone is covered under the prescription drug benefit.

$15 per office visit

60 consecutive days per condition for the services of each of the following:

qualified physical therapists and

occupational therapists

Note: We only cover therapy to restore bodily function when there has been a total or partial loss of bodily function due to illness or injury.

Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction is provided for up to 60 days for physical therapy.

20% of charges

Not covered:

Long-term rehabilitative therapy

Exercise programs

All charges.

60 consecutive days per condition

20% of charges.

Hearing testing for children through age 17 (see Preventive care, children)

$15 per office visit

Not covered:

All other hearing testing

Hearing aids, testing and examinations for them

All charges.

Diagnosis and treatment of diseases of the eye

$15 per office visit

Prosthetic devices, such as lenses following cataract removal

50% of charges

Not covered:

Eyeglasses or contact lenses and after age 17, examinations for them

Eye exercises and orthoptics

Radial keratotomy and other refractive surgery

Annual eye refractions

All charges.

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

Note: See Orthopedic and prosthetic devices for information on podiatric shoe inserts.

$15 per office visit

Not covered:

Cutting, trimming or removal of corns, calluses, or the free edge of toenails, and similar routine treatment of conditions of the foot, except as stated above

Treatment of weak, strained or flat feet or bunions or spurs; and of any instability, imbalance or subluxation of the foot (unless the treatment is by open cutting surgery)

All charges.

Our maximum allowance for this benefit is $1,000 per calendar year

Artificial limbs and eyes; stump hose

Externally worn breast prostheses and surgical bras, including necessary replacements following a mastectomy

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

Orthopedic devices, such as braces

Foot orthotics

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

Nothing up to our maximum allowance of $1,000 per calendar year

Not covered:

Heel pads and heel cups

Lumbosacral supports

Corsets, trusses, elastic stockings, support hose, and other supportive devices

All charges.

Our maximum allowance for this benefit is $1,000 per calendar year

Rental or purchase, at our option, including repair and adjustment, of durable medical equipment prescribed by your Plan physician, such as oxygen and dialysis equipment. Under this benefit, we also cover:

Hospital beds;

Wheelchairs;

Crutches;

Walkers;

Blood glucose monitors; and

Insulin pumps.

Note: Call us at 800-341-6613 as soon as your Plan physician prescribes this equipment.

Nothing up to our maximum allowance of $1,000 per calendar year

Not covered: Motorized wheelchairs.

All charges.

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

Not covered:

Nursing care requested by, or for the convenience of, the patient or the patient's family;

Home care primarily for personal assistance that does not include a medical component and is not diagnostic, therapeutic, or rehabilitative.

Nursing aides

All charges.

Manipulation of the spine and extremities

After initial evaluation, treatment plan must be submitted to Coventry Health Care to authorize additional visits.

$15 per office visit

No benefit

All charges

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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.

Plan physicians must provide or arrange your care.

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

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

YOUR PHYSICIAN MUST GET PRECERTIFICATION OF SOME 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.

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A comprehensive range of services, such as:

Operative procedures

Treatment of fractures, including casting

Normal pre- and post-operative care by the surgeon

Correction of amblyobia and strabismus

Endoscopy procedures

Biopsy procedures

Removal of tumors and cysts

Correction of congenital anomalies (see Reconstructive surgery)

$15 per office visit

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 prosthetic devices. See 5(a) - Orthopedic and prosthetic devices for device coverage information

Treatment of burns

$15 per office visit

Voluntary sterilization (e.g., Tubal ligation, Vasectomy)

$100 per procedure

Not covered:

Reversal of voluntary sterilization

Routine treatment of conditions of the foot; see Foot care

All charges.

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

- 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.

All stages of breast reconstruction surgery following a mastectomy, such as:

- surgery to produce a symmetrical appearance of breasts;

- 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.

$15 per office visit

Not covered:

Cosmetic surgery - any surgical procedure (or any portion of a procedure) performed primarily to improve physical appearance through change in bodily form, except repair of accidental injury

Surgeries related to sex transformation

All charges.

Oral 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.

TMJ treatment and services (non-dental)

$15 per office visit

Not covered:

Oral implants and transplants

Procedures that involve the teeth or their supporting structures (such as the periodontal membrane, gingiva, and alveolar bone)

Dental care involved in treatment of temporomandibular joint (TMJ) pain dysfunction syndrome

All charges.

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

Intestinal transplants (small intestine) and the small intestine with the liver or small intestine with multiple organs such as the liver, stomach, and pancreas

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

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

$15 per office visit

Organ/tissue transplants - continued on next page

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.

Professional services provided in -

Hospital (inpatient)

Nothing

Professional services provided in -

Hospital outpatient department

Skilled nursing facility

Ambulatory surgical center

Office

$15 per office visit

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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.

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 in Sections 5(a) or (b).

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

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Room and board, such as

Ward, semiprivate, or intensive care accommodations;

General nursing care; and

Meals and special diets.

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

$100 per day up to a $300 maximum per admission and nothing for other services

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 plasma

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 for other hospital services after you pay the hospital admission copayment.

Not covered:

Custodial care

Non-covered facilities, such as nursing homes, schools

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

Blood

Private nursing care

All charges.

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

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.

$50 copayment

Not covered: Blood and blood derivatives not replaced by the member

All charges.

Comprehensive range of benefits will be provided for up to 100 days per calendar year when full-time skilled nursing care is necessary and confinement in a skilled nursing facility is in lieu of hospitalization..

Covered services include:

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.