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 1-800-635-6668 or write to us at 1600 E. Hill Street, Signal Hill, CA 90755.

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. Universal Care's Plan providers include Primary Care Physicians, specialty physicians, physician assistants and nurse practitioners.

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

· 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 (www.universalcare.com).

What you must do to get covered care

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. To select your Primary Care Physician, call our Member Services Department at 1-800-635-6668.

· Primary care

Your primary care physician can be a family practitioner, internist, pediatrician, or general practitioner. 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. When you receive a referral from your primary care physician, you must return to the primary care physician after the consultation, unless your primary care physician authorized a certain number of visits without additional referrals. The primary care physician must provide or authorize all follow-up care. Do not go to the specialist for return visits unless your primary care physician gives you a referral. However, you may see OB/GYN or an Internist without a referral. Generally, your Primary Care Physician will refer you to a specialist within your Contracted Medical Group. If you require services that are not available within your Contracted Medical Group, the Primary Care Physician will arrange for a referral to a Contracted Provider within Universal Care's network. To order certain services, the Primary Care Physician will give you a written referral authorizing such services. For certain specialty services, the referral is submitted by the Primary Care Physician for review for Prior Authorization to Universal Care or to the Contracted Medical Group's Utilization Review Committee.

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

· If you need to see a specialist frequently because of a chronic, complex, or serious medical condition, your primary care physician will develop a treatment plan that allows you to see your specialist for a certain number of visits without additional referrals. Your primary care physician will use our criteria when creating your treatment plan (the physician may have to get an authorization or approval beforehand).

· If you are seeing a specialist when you enroll in our Plan, talk to your primary care physician. Your primary care physician will decide what treatment you need. If he or she decides to refer you to a specialist, ask if you can see your current specialist. If your current specialist does not participate with us, you must receive treatment from a specialist who does. Generally, we will not pay for you to see a specialist who does not participate with our Plan.

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

· If you have a chronic 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 1-800-635-6668. 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

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 Prior Authorization. Your physician must obtain Prior Authorization for the following services,which include, but are not limited to:

· Referrals to specialists

· Laboratory and Radiology services such as Blood Tests, Urinalysis, Non-routine pap tests, Pathology, X-rays, Non-routine mammograms, Cat Scans/MRI, Ultrasound, Electrocardiogram and EEG

· Elective procedures-inpatient or outpatient

· Home health care

· Durable Medical Equipment

· Ambulance

Your physician must get our approval before sending you to a hospital, referring you to a specialist, or recommending follow-up care. Prior Authorization means that your Primary Care Physician must contact Universal Care (or in some cases, the Contracted Medical Group with which your Primary Care Physician is affiliated) to request that the service be approved for coverage before services are rendered. Requests for Prior Authorization will be denied if the requested services are determined to be not Medically Necessary. Requests for Prior Authorization of coverage for services by non-contracted providers will also be denied if Universal Care determines that comparable or more appropriate services are available through Universal Care's Contracted Providers.

The majority of requests for Prior Authorization of coverage are responded to within 72 hours of their receipt, and urgent matters are expedited. Those requests which require investigation and/or physician review sometimes take longer as they may be needed for additional information and communication directly to you and your Primary Care Physician and the referral specialist along with an authorization number. Requests for coverage that are approved by Universal Care are communicated directly to you and your Primary Care Physician and the referral specialist along with an authorization number. Requests for Prior Authorization of coverage that are denied by Universal Care are communicated in writing to your Primary Care Physician and you.

In the event that Prior Authorization of coverage has been denied by Universal Care (or in some cases, the Utilization Review Committee of your Contracted Medical Group), you, or your Primary Care Physician on your behalf may appeal the denial by following the appeals process outlined on page of this brochure. If you would like a more detailed description of Universal Care's Criteria for Authorizing or Denying Health Care Services, you may contact Universal Care's Member Services Department at 800-635-6668.

Copayments

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

Example: When you see your primary care physician you pay a copayment of $10 per office visit and when you go in the hospital, you pay $300 per admission.

Deductible

We do not have a deductible.

Coinsurance

We do not have coinsurance.

Your catastrophic protection out-of-pocket maximum

After your copayments total $2,000 per person or $4,000 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 catastrophic protection out-of-pocket maximum, and you must continue to pay copayments for these services:

· Prescription drugs

· Durable Medical Equipment

· Diagnosis and treatment of infertility

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

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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.

· 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.

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Professional services of physicians

· In physician's office

$10 per office visit

Professional services of physicians

· In an urgent care center

· During a hospital stay

· In a skilled nursing facility

· Office medical consultations

· Second surgical opinion

$10 per office visit

At home visits by nurse or health aide

Nothing

At home visits by physician

$10 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 if you receive these services during your office visit; otherwise, $10 per office visit

Routine screenings, such as:

· Total Blood Cholesterol

· Colorectal Cancer Screening, including

· Fecal occult blood test

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

· Venereal Disease testing, including screening for chlamydial infection

· Breast Cancer Screening

$10 per office visit

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

$10 per office visit

Routine pap test

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

$10 per office visit

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

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

· From age 40 through 64, one every calendar year

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

$10 per office visit

Routine immunizations, limited to:

· Tetanus-diphtheria (Td) booster - once every 10 years, ages 19 and over (except as provided for under Childhood immunizations)

· Influenza vaccine, annually

· Pneumococcal vaccine, age 65 and older

$10 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

$10 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)

$10 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 28 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 office visit

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

All charges.

A range of voluntary family planning services, limited to:

· Voluntary sterilization (See Surgical procedures Section 5 (b))

· Surgically implanted contraceptives

· Injectable contraceptive drugs (such as Depo provera)

· Intrauterine devices (IUDs)

· Diaphragms

· Abortion only when the life of the mother would be endangered if fetus is carried to term or if the pregnancy is a result of an act of rape or incest.

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

$10 per office visit

$200 copay

Not covered:

· Reversal of voluntary surgical sterilization

· Genetic counseling.

All charges.

Diagnosis and treatment of infertility such as:

· Artificial insemination:

· intravaginal insemination (IVI)

· intracervical insemination (ICI)

· intrauterine insemination (IUI)

· Fertility drugs

Note: We cover injectible fertility drugs under medical benefits and oral fertility drugs under the prescription drug benefit.

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

All charges.

· Testing and treatment

· Allergy injections

$10 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 26.

· Respiratory and inhalation therapy

· Dialysis - hemodialysis and peritoneal dialysis

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

· Growth hormone therapy (GHT)

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

Note: - We only cover GHT when we preauthorize the treatment. Call 800-635-6668 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 office visit

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

· Cardiac rehabilitation following a heart transplant, bypass surgery or a myocardial infarction is provided for up to 60 sessions.

$10 per office visit

$10 per outpatient visit

Nothing per visit during covered inpatient admission

Not covered:

· Long-term rehabilitative therapy

· Exercise programs

All charges.

60 visits per year

$10 per office visit

$10 per outpatient visit

Nothing per visit during covered inpatient admission.

· First hearing aid and testing only when necessitated by accidental injury

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

$10 per office visit

Not covered:

· All other hearing testing

· Hearing aids, testing and examinations for them

All charges.

· One pair of eyeglasses or contact lenses to correct an impairment directly caused by accidental ocular injury or intraocular surgery (such as for cataracts)

· Diagnosis and treatment of diseases of the eye.

Note: See Preventive care, children for exams for children

$10 per office visit

Not covered:

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

· Eye exercises and orthoptics

· Radial keratotomy and other refractive surgery

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.

$10 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.

· 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

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

· Maximum benefit of $2,500 per Calendar Year

Note: The maximum benefit is $2,500 per calendar year per member

10% of allowed charges

Not covered:

· Orthopedic and corrective shoes

· Arch supports

· Foot orthotics

· Heel pads and heel cups

· Lumbosacral supports

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

· Prosthetic replacements provided less than 3 years after the last one we covered

All charges.

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.

· Wigs are covered only for members undergoing chemotherapy or radiation treatment.

Note: Call us at 800-635-6668 as soon as your Plan physician prescribes this equipment. We will arrange with a health care provider to rent or sell you durable medical equipment at discounted rates and will tell you more about this service when you call.

Note: The maximum benefit is $2,500 per calendar year per member

10% of allowed charges

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.

$10 per office visit

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.

All charges.

No Benefit

All charges.

No Benefit

All charges.

Coverage is limited to:

· Smoking Cessation - Up to $100 for one smoking cessation program per member per lifetime, including all related expenses such as drugs.

· Diabetes self management

· Weight Loss

· Cholesterol control

· Exercise

· Parenting

· Healthy kids

· Breast feeding

· Healthy Living: Fast foods/Dining out

· Hypertension management

· Stress Management

· Healthy Living Back

· Asthma control: Children (ages 4-8)

Teens (ages 9-14)

Adults (ages 15+)

Nothing

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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.

· 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.).

· YOU MUST GET PRIOR AUTHORIZATION FOR ALL 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 amblyopia and strabismus

· Endoscopy procedures

· Biopsy procedures

· 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. Surgery for morbid obesity will be performed only as a last resort, when the members health is endangered and more conservative medical measures, including prescription drugs such as appetite suppressants, have not been successful.

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

$10 per office visit

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

· 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.

Note: All elective procedures must be prior approved by the Plan.

$100 per office visit - Vasectomy

$200 per office visit - Tubal ligation

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

· 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.

· 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 prosthese