RI 71-004

APWU Health Plan 1999 A Managed Fee- for- Service Plan with Preferred Provider Organizations

Sponsored by the American Postal Workers Union, AFL- CIO Who may enroll in this Plan:

All Federal and Postal Service employees and annuitants who are eligible to enroll in the FEHB Program may become members of this Plan. To enroll, you must be, or must become, a member of the American Postal Workers Union, AFLCIO. Annuitants (retirees) may enroll in this Plan.

To become a member or associate member:

All active Postal Service bargaining unit employees must be, or must become, dues- paying members of the APWU, except where exempt by law. In item 1 of Part B of your registration form, enter the number of your APWU Local immediately after the name of this Plan.

If you are a non- postal employee/ annuitant, you will automatically become an associate member of APWU upon enrollment in the APWU Health Plan.

Membership dues: $35 per year for associate members. New associate members will be billed for annual dues when the Plan receives notice of enrollment. Continuing associate members will be billed by the Plan for the annual membership. Billing usually takes place at the end of March. Please do not send money to the Health Plan; APWU headquarters will bill you for the dues.

Enrollment code for this Plan: 471 Self only 472 Self and family

Visit the OPM website at http:// www. opm. gov/ insure and this Plans Web site at http:// www. apwuhp. com

RI 71- 004

United States Office of Personnel Management Authorized for distribution by the:

1999 RI 71- 004 2

American Postal Workers Union Health Plan

The American Postal Workers Union, Washington, DC, (Carrier) has entered into Contract No. CS 1370 with the Office of Personnel Management (OPM) to provide a health benefits plan (Plan) authorized by the Federal Employees Health Benefits (FEHB) law. The FEHB contract specifies the manner in which it may be modified or terminated.

This brochure is the official statement of benefits on which you can rely. It describes the benefits, exclusions, limitations, and maximums of the APWU Health Plan for 1999 and until amended by future benefit negotiations between OPM and the Carrier. It also describes procedures for obtaining benefits. You should use this brochure to determine your entitlement to benefits. Oral statements cannot modify the benefits described in this brochure.

An enrollee does not have a vested right to receive the benefits in this brochure in 2000 or later years, and does not have a right to benefits available prior to 1999 unless those benefits are contained in this brochure.

Inspector General Advisory: Stop Health Care Fraud!

Fraud increases the cost of health care for everyone. Anyone who intentionally makes a false statement or a false claim in order to obtain FEHB benefits or increase the amount of FEHB benefits is subject to prosecution for FRAUD which may result in CRIMINAL PENALTIES.

Please review all medical bills, medical records and claims statements carefully. If you find that a provider, such as a doctor, hospital, pharmacy, etc., charged your Plan for services you did not receive, billed for the same service twice, or misrepresented any other information, take the following actions:

Call the provider (doctor, hospital, etc.) and ask for an explanation - sometimes the problem is a simple error.

If the provider does not resolve the matter, or if you remain concerned, call your Carrier at 1- 800/ 222- APWU and explain the situation.

If the matter is not resolved after speaking to your Carrier (and you still suspect fraud has been committed), call or write:

THE HEALTH CARE FRAUD HOTLINE 202/ 418- 3300

The Office of Personnel Management Office of the Inspector General Fraud Hotline

1900 E Street, N. W., Room 6400 Washington, D. C. 20415 The inappropriate use of membership identification cards, e. g., to obtain benefits for a person who is not an eligible family member or after you are no longer enrolled in the Plan, is also subject to review by the Inspector General and may result in an adverse administrative action by your agency.

When you need help with Plan benefits, or getting your ID card, call your Plan at 1- 800/ 222- APWU. The Fraud Hotline cannot help you with these.

Using This Brochure

The Table of Contents will help you find the information you need to make the best use of your benefits. To get the best value for your money, you should read Facilities and Other Providers. It will help you understand how your choice of doctors and hospitals will affect how much you pay for services under this Plan.

This brochure explains all of your benefits. It's important that you read about your benefits so you will know what to expect when a claim is filed. Most of the benefit headings are self- explanatory. Other Medical Benefits and Additional Benefits, on the other hand, both include a variety of unrelated benefits. What is different about these benefits is how they are paid: Other Medical Benefits are paid after you satisfy the calendar year deductible and Additional Benefits are generally not subject to the calendar year deductible.

You will find that some benefits are listed in more than one section of the brochure. This is because how they are paid depends on which provider bills for the service. For example, physical therapy is paid one way if it is billed by an inpatient facility and paid another way when it is billed by a doctor, physical therapist or outpatient facility.

The last part of the brochure contains information useful to you under certain circumstances. For example, if you have to go to the hospital you need to read Precertification; hospital stays must be precertified for all payable benefits to apply. If you are enrolled in Medicare, take a look at This Plan and Medicare. And, the Enrollment Information section tells you about several FEHB enrollment requirements that could affect your future coverage.

1999 RI 71- 004 3

Table of Contents Page

How This Plan Works

Help Contain Costs............................................................................................................................................................. 5 Ways you and the Carrier can work together to keep costs down

Facilities and Other Providers ..................................................................................................................................... 5- 7 Medical personnel and facilities covered by this Plan and how your choice of provider will affect what you pay for benefits

Cost Sharing ...................................................................................................................................................................... 7- 8 What you need to know about deductibles, coinsurance and copayments, your share of covered health care expenses, and the maximum amounts this Plan will pay for certain types of care

General Limitations................................................................................................................................ 8- 10 How the Plan works if you have other health care coverage or receive health care services through another Government program; limit on your costs if you are 65 or older and dont have Medicare

General Exclusions............................................................................................................................................................ 11 What is not covered by this Plan

Benefits

Inpatient Hospital Benefits ....................................................................................................................................... 12- 13 Your benefits for inpatient hospital care (see below for mental conditions/ substance abuse care)

Surgical Benefits........................................................................................................................................................... 13- 15 Your benefits for doctors' services for inpatient and outpatient surgery and related procedures

Maternity Benefits ...................................................................................................................................................... 16- 17 Your benefits for prenatal care, childbirth, contraceptives, and infertility treatment

Mental Conditions/ Substance Abuse Benefits ......................................................................................................... 18 Your benefits for outpatient, inpatient and other facility care for mental conditions, alcoholism and drug abuse

Other Medical Benefits (deductible applies) ...................................................................................................... 19- 21 Your benefits for doctors' hospital, home and office visits, routine health screening services, lab tests and X- rays, durable medical equipment (e. g., crutches and hospital beds), home nursing services, allergy tests and injections, chemotherapy, radiation therapy and physical, occupational and speech therapy

Additional Benefits (no deductible)............................................................................................................................ 22 Your benefits for outpatient care for accidental injury, 24- hour nurse advisory, hospice care, well child care, childhood immunizations, Wellness benefit and Review and reward program

1999 RI 71- 004 4

Table of Contents continued

Page

Benefits (continued)

Prescription Drug Benefits........................................................................................................................................ 23- 24 Your benefits for prescription drugs and supplies you get from pharmacies or by mail order

Dental Benefits .............................................................................................................................................................. 24- 26 Your benefits for dental care

How to Claim Benefits................................................................................................................................................ 26- 28 Getting your claims paid when your provider does not file them for you; how to ask OPM to review a claims dispute between you and the Carrier

Protection Against Catastrophic Costs ...................................................................................................................... 29 The maximum amount of covered expenses you can expect to pay for health care

Other Information

Information You Have a Right to Know ................................................................................................. 30

Precertification.............................................................................................................................................................. 30- 31 Hospital stays must be precertified to avoid a $500 benefit reduction

This Plan and Medicare ............................................................................................................................................. 31- 33 Information you need if you are covered by Medicare

Enrollment Information............................................................................................................................................. 33- 36 Your enrollment in the Federal Employees Health Benefits Program and how to maintain FEHB coverage when enrollment ends

Definitions....................................................................................................................................................................... 36- 39 Explanations of some of the terms used in this brochure

Index ......................................................................................................................................................... 40 List of covered benefits and services, by page number

How This Plan Changes

How the APWU Health Plan Changes January 1999............................................................................................ 41

Summary of Benefits

High Option ........................................................................................................................................................................ 42

Rate Information ...................................................................................................................................... 44

1999 RI 71- 004 5

How This Plan Works

Help Contain Costs You can help FEHB plans are expected to manage their costs prudently. All FEHB plans have cost containment

measures in place. All fee- for- service plans include two specific provisions in their benefits packages: precertification of all inpatient admissions and the flexible benefits option. Some include managed care options, such as PPOs, to help contain costs.

As a result of your cooperative efforts, the FEHB Program has been able to control premium costs. Please keep up the good work and continue to help keep costs down.

Precertification Precertification evaluates the medical necessity of proposed admissions and the number of hospital days required to treat your condition. You are responsible for ensuring that the precertification requirement is met. You or your doctor must check with your Plan before being admitted to the hospital. If that doesn't happen, your Plan will reduce benefits by $500. Be a responsible consumer. Be aware of your Plan's cost containment provisions. You can avoid penalties and help keep premiums under control by following the procedures specified on page 30 of this brochure.

Flexible benefits option Under the flexible benefits option, the Carrier has the authority to determine the most effective way to provide services. The Carrier may identify medically appropriate alternatives to traditional care and coordinate the provision of Plan benefits as a less costly alternative benefit. Alternative benefits are subject to ongoing review. The Carrier may decide to resume regular contract benefits at its sole discretion. Approval of an alternative benefit is not a guarantee of any future alternative benefits. The decision to offer an alternative benefit is solely the Carriers and may be withdrawn at any time. It is not subject to OPM review under the disputed claims process.

PPO This Plan offers most of its members the opportunity to reduce out- of- pocket expenses by choosing providers who participate in the Plan's preferred provider organization (PPO). Consider the PPO cost savings when you review Plan benefits and check with the Carrier to see whether PPO providers are available in your area.

In addition to a preferred provider network, your Plan has discount arrangements with other hospitals around the country. Their terms vary, but the purpose is the same: to reduce your out- ofpocket expenses on covered services.

Facilities and Other Providers Covered facilities

Freestanding ambulatory facility

An out- of- hospital facility such as a medical, cancer, dialysis, or surgical center or clinic, and licensed outpatient facilities accredited by the Joint Commission on Accreditation of Healthcare Organizations for treatment of substance abuse.

Hospital 1) An institution which is accredited as a hospital under the Hospital Accreditation Program of the Joint Commission on Accreditation of Healthcare Organizations, or 2) Any other institution which is operated pursuant to law, under the supervision of a staff of doctors

and twenty- four hour a day nursing service, and which is primarily engaged in providing: a) general inpatient care and treatment of sick and injured persons through medical,

diagnostic and major surgical facilities, all of which must be provided on its premises or under its control, or

b) specialized inpatient 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 (as defined above) or with a specialized provider of those facilities.

The term "hospital" shall not include a skilled nursing facility, a convalescent nursing home or institution or part thereof which 1) is used principally as a convalescent facility, rest facility, residential treatment center, nursing facility or facility for the aged or 2) furnishes primarily domiciliary or custodial care, including training in the routines of daily living.

1999 RI 71- 004 6

Facilities and Other Providers continued

Covered providers For purposes of this Plan, covered providers include: 1) Doctor - A licensed doctor of medicine (M. D.), a licensed doctor of osteopathy (D. O.), a

licensed doctor of podiatry (D. P. M.), or, for certain specified services covered by this Plan, a licensed dentist, licensed chiropractor, or licensed clinical psychologist practicing within the scope of the license.

2) Alternate Provider - Alternate providers are covered when performing certain specified services covered by this Plan and when such treatment is within the scope of the provider's license. Alternate providers are limited to licensed physical, occupational and speech therapists; licensed physicians assistants; Registered Nurses (R. N.); Licensed Practical Nurses (L. P. N.); Licensed Vocational Nurses (L. V. N.); and Certified Registered Nurse Anesthetists (C. R. N. A.).

3) Other covered providers include a qualified clinical psychologist, clinical social worker, optometrist, nurse midwife, nurse practitioner/ clinical specialist, and nursing school administered clinic. For purposes of this FEHB brochure, the term "doctor" includes all of these providers when the services are performed within the scope of their license or certification.

Coverage in medically underserved areas

Within States designated as medically underserved areas, any licensed medical practitioner will be treated as a covered provider for any covered services performed within the scope of that license. For 1999, the States designated as medically underserved are: Alabama, Idaho, Louisiana, Mississippi, New Mexico, North Dakota, South Carolina, South Dakota and Wyoming.

PPO arrangements Benefits under this Plan are available from facilities, such as hospitals, and from providers, such as pharmacies, doctors and other health care personnel, who provide covered services. This Plan

covers two types of facilities and providers: (1) those who participate in a preferred provider organization (PPO) and (2) those who do not. Who these health care providers are, and how benefits are paid for their services, are explained below. In general, it works like this.

PPO facilities and providers have agreed to provide services to Plan members at a lower cost than you'd usually pay a non- PPO provider. Although PPOs are not available in all locations or for all services, when you use these providers you help contain health care costs and reduce what you pay out of pocket. The selection of PPO providers is solely the Carriers responsibility; continued participation of any specific provider cannot be guaranteed. While PPO providers agree with the Carrier to provide covered services, final decisions about health care are the sole responsibility of the doctor and patient and are independent of the terms of the insurance contract.

PPO benefits apply only when you use a PPO provider. Provider networks may be more extensive in some areas than others. The availability of every specialty in all areas cannot be guaranteed. If no PPO provider is available, or you do not use a PPO provider, the standard non- PPO benefits apply.

When you use a PPO hospital, keep in mind that the professionals who provide services to you in the hospital, such as radiologists, anesthesiologists and pathologists, may not all be preferred providers. If they are not, they will be paid by this Plan as non- PPO providers.

Non- PPO facilities and providers do not have special agreements with the Plan. The Plan makes its regular payments toward the bills, and you are responsible for any balance.

This Plan's PPO

The Plan has established a network of doctors and hospitals that have agreed to reduce their charges to members who voluntarily seek them out for covered services. If you are admitted to a PPO hospital, the Plan will pay 90% of covered Inpatient hospital charges. Precertification of all hospital admissions is still required as outlined on page 30. If you use the services of a PPO doctor, the Plan will pay in full after a $15 copayment for outpatient visits and pay 90% of other covered reasonable and customary charges.

Enrollees who reside in a PPO area will receive information concerning the PPO in their region. Additional locations may become available throughout 1999. If you need assistance in identifying a participating provider, call the Plans PPO administrator for your state: Alliance PPO, Inc. 1- 800/ 342- 3289 for providers in the District of Columbia, Maryland, Virginia and West Virginia; Beech Street 1- 800/ 923- 3248 for providers in California, Florida, Georgia, Ohio, Oklahoma,

1999 RI 71- 004 7

Facilities and Other Providers continued

This Plan's PPO (continued)

Tennessee, Texas and Washington; MultiPlan 1- 800/ 672- 2140 for providers in New Jersey and New York; MedNet 1- 800/ 556- 1144 for providers in Maine; PreferredOne 1- 800/ 451- 9597 for providers in Minnesota; or First Health 1- 800/ 447- 1704 for all other states. For mental conditions/ substance abuse providers (all states), call ValueOptions toll- free 1- 888/ 700- 7965. Including a provider in the PPO does not represent a warranty of services by the Plan nor does it constitute medical advice. When you phone for an appointment, please remember to verify that the physician is still a PPO provider.

Cost Sharing Deductibles A deductible is the amount of expense an individual must incur for covered services and supplies

before the Plan starts paying benefits for the expense involved. A deductible is not reimbursable by the Plan and benefits paid by the Plan do not count toward the deductible. When a benefit is subject to a deductible, only expenses allowable under that benefit count toward the deductible.

Calendar year The calendar year deductible is the amount of expense an individual must incur for covered services and supplies each calendar year before the Plan pays certain benefits. The deductible is $250 and applies to Surgical Benefits, Maternity Benefits, and Other Medical Benefits.

Hospital admission The per admission deductible is the amount of covered room and board expenses an individual must incur during each non- PPO hospital admission before the Plan pays benefits. The per admission deductible is $200.

Prescription drugs A prescription drug deductible applies to drugs obtained through a retail pharmacy. This deductible is $50 per person each calendar year (maximum $100 per Self and family enrollment per year). Drugs obtained through the mail order drug program are not subject to any deductible.

Mental conditions/ Substance abuse A separate deductible applies each calendar year to covered services for inpatient and/ or outpatient

treatment of mental conditions or substance abuse. This deductible is $250 per person for services by a PPO provider or $750 per person for services by a non- PPO provider.

Carryover If you changed to this Plan during open season from a plan with a deductible and the effective date of the change was after January 1, any expenses that would have applied to that plans deductible in

the prior year will be covered by your old plan if they are for care you got in January before the effective date of your coverage in this Plan. If you have already met the deductible in full, your old plan will reimburse these covered expenses. If you have not met it in full, your old plan will first apply your covered expenses to satisfy the rest of the deductible and then reimburse you for any additional covered expenses. The old plan will pay these covered expenses according to this years benefits; benefit changes are effective on January 1.

Family limit There is a separate calendar year deductible of $250 per person. However, under a family enrollment, when the combined covered expenses applied to the deductible for all family members reach $500 during a calendar year, the family deductible is satisfied and benefits for which the calendar year deductible applies are payable for all family members.

Coinsurance Coinsurance is the stated percentage of covered charges you must pay after you have met any applicable deductible. The Plan will base this percentage on either the billed charge or the reasonable and customary charge, whichever is less. For instance, when a plan pays 80 percent of reasonable and customary charges for a covered service, you are responsible for 20 percent of the reasonable and customary charges, i. e., the coinsurance. In addition, you may be responsible for any excess charge over the Plan's reasonable and customary allowance. For example, if the provider ordinarily charges $100 for a service but the Plan's reasonable and customary allowance is $95, the Plan will pay 80 percent of the allowance ($ 76). You must pay the 20 percent coinsurance ($ 19), plus the difference between the actual charge and the reasonable and customary allowance ($ 5), for a total member responsibility of $24. Remember, if you use preferred providers, your share of covered charges (after meeting any deductible) is limited to the stated coinsurance amount.

1999 RI 71- 004 8

Cost Sharing continued

When hospital charges are limited by law

When inpatient claims are paid according to a Diagnostic Related Group (DRG) limit (for instance, for admissions of certain retirees who do not have Medicare - see page 9), the Plan will pay 30 percent of the total covered amount as room and board charges and 70 percent as other charges and will apply your coinsurance accordingly.

Copayments A copayment is the stated amount the Plan requires you to pay for certain covered services, such as $15 per office visit at a PPO provider.

If provider waives your share If a provider routinely waives (does not require you to pay) your share of the charge for services

rendered, the Plan is not obligated to pay the full percentage of the amount of the provider's original charge it would otherwise have paid. A provider or supplier who routinely waives coinsurance, copayments or deductibles is misstating the actual charge. This practice may be in violation of the law. The Plan will base its percentage on the fee actually charged. For example, if the provider ordinarily charges $100 for a service but routinely waives the 20% coinsurance, the actual charge is $80. The Plan will pay $64 (80% of the actual charge of $80).

Lifetime maximums For Smoking Cessation Benefit, the Plan will pay up to $100 for enrollment in one smoking cessation program per member per lifetime.

For substance abuse, the Plan will pay up to $3,000 for one treatment program per member per lifetime.

General Limitations

All benefits are subject to the definitions, limitations and exclusions in this brochure and are payable when determined by the Carrier to be medically necessary. Coverage is provided only for services and supplies that are listed in this brochure. No oral statement of any person shall modify or otherwise affect the benefits, limitations and exclusions of this brochure, convey or void any coverage, increase or reduce any benefits under the Plan or be used in the prosecution or defense of a claim under the Plan.

This brochure is the official statement of benefits on which you can rely.

Other sources of benefits This section applies when you or your family members are entitled to benefits from a source other than this Plan. You must disclose information about other sources of benefits to the Carrier and complete all necessary documents and authorizations requested by the Carrier.

Medicare If you or a covered family member is enrolled in this Plan and Part A, Part B, or Parts A and B of Medicare, the provisions on coordination of benefits with Medicare described on pages 31 - 33 apply.

Group health insurance and automobile insurance

Coordination of benefits (double coverage) applies when a person covered by this Plan also has, or is entitled to benefits from, any other group health coverage, or is entitled to the payment of medical and hospital costs under no- fault or other automobile insurance that pays benefits without regard to fault. Information about the other coverage must be disclosed to this Carrier.

When there is double coverage, one plan normally pays its benefits in full as the primary payer, and the other plan pays a reduced benefit as the secondary payer. When this Plan is the secondary payer, it will pay the lesser of (1) its benefits in full, or (2) a reduced amount that, when added to the benefits payable by the other coverage, will not exceed 100 % of covered expenses. When this Plan pays secondary, it will only make up the difference between the primary plans coverage and this Plans coverage. Thus, the combined payments from both plans may not equal the entire amount billed by the provider.

The determination of which health coverage is primary (pays its benefits first) is made according to guidelines provided by the National Association of Insurance Commissioners (NAIC). When benefits are payable under automobile insurance, including no- fault, the automobile insurer is primary (pays its benefits first) if it is legally obligated to provide benefits for health care expenses without regard to other health benefits coverage the enrollee may have.

This provision applies whether or not a claim is filed under the other coverage. When applicable, authorization must be given this Carrier to obtain information about benefits or services available from the other coverage, or to recover overpayments from other coverages.

CHAMPUS If you are covered by both this Plan and the Civilian Health and Medical Program of the Uniformed Services (CHAMPUS), this Plan will pay benefits first.

Medicaid If you are covered by both this Plan and Medicaid, this Plan will pay benefits first.

1999 RI 71- 004 9

General Limitations continued

Workers compensation The Plan will not pay for benefits or services required as the result of occupational disease or injury for which any medical benefits are determined by the Office of Workers Compensation Programs (OWCP) to be payable under workers compensation (under section 8103 of title 5, U. S. C.) or by a similar agency under another Federal or State law. This provision also applies when a third party injury settlement or other similar proceeding provides medical benefits in regard to a claim under workers compensation or similar laws. If medical benefits provided under such laws are exhausted, medical benefits may be provided for services or supplies covered by this Plan. The Plan is entitled to be reimbursed by OWCP (or the similar agency) for benefits paid by the Plan that were later found to be payable by OWCP (or the agency).

DVA facilities, DoD facilities, and Indian Health Service

Facilities of the Department of Veterans Affairs, the Department of Defense, and the Indian Health Service are entitled to seek reimbursement from the Plan for certain services and supplies provided to you or a family member to the extent that reimbursement is required under the Federal statutes governing such facilities.

Other government agencies The Plan will not provide benefits for services and supplies paid for directly or indirectly by any other local, State, or Federal Government agency.

Liability insurance and third party actions

Subrogation applies when you are sick or injured as a result of the act or omission of another person or party.

If you or your dependent sustains an injury or illness caused by a third party, the Plan will pay benefits for the injury or illness, subject to the conditions that you and your dependents (1) agree to the Plan being subrogated to any recovery or right of recovery you or your dependents have, including the right to bring suit in your name; (2) will not take any action which would prejudice the Plans subrogation rights; and (3) will cooperate in doing what is reasonably necessary to assist the Plan in any recovery. The Plan will be subrogated only to the extent of Plan benefits paid because of that injury.

This provision means that the Plan must be reimbursed in full for benefits paid in an amount not to exceed the amount you recover, or, if you do not bring suit or recover, that the Plan, to the extent of benefits paid, has a right to bring suit in the name( s) of the injured party or parties. Under this provision all recoveries (whether by lawsuit, settlement or otherwise), no matter how described or designated, must be used to reimburse the Plan in full for benefits paid. This provision does not allow the Plans share of the recovery to be reduced because you or your covered dependent do not receive the full amount of damages claimed or for your attorneys fees and costs, unless the Plan agrees in writing to a reduction.

Overpayments The Carrier will make reasonable diligent efforts to recover benefit payments made erroneously but in good faith and may apply subsequent benefits otherwise payable to offset any overpayments.

Vested rights An enrollee does not have a vested right to receive the benefits in this brochure in 2000 or later years, and does not have a right to benefits available prior to 1999 unless those benefits are

contained in this brochure.

Limit on your costs if you are age 65 or older and don't have Medicare

The information in the following paragraphs applies to you when 1) you are not covered by either

Medicare Part A (hospital insurance) or Part B (medical insurance), or both, 2) are enrolled in this Plan as an annuitant or as a former spouse or family member covered by the family enrollment of an annuitant or former spouse, and 3) you are not employed in a position which confers FEHB coverage.

Inpatient hospital care

If you are not covered by Medicare Part A, are age 65 or older or become age 65 while receiving inpatient hospital services, and you receive care in a Medicare participating hospital, the law (5 U. S. C. 8904( b)) requires the Plan to base its payment on an amount equivalent to the amount Medicare would have allowed if you had Medicare Part A. This amount is called the equivalent Medicare amount. After the Plan pays, the law prohibits the hospital from charging you for covered services after you have paid any deductibles, coinsurance, or copayments you owe under the Plan. Any coinsurance you owe will be based on the equivalent Medicare amount, not the actual charge. You and the Plan, together, are not legally obligated to pay the hospital more than the equivalent Medicare amount.

The Carriers explanation of benefits (EOB) will tell you how much the hospital can charge you in addition to what the Plan paid. If you are billed more than the hospital is allowed to charge, ask the hospital to reduce the bill. If you have already paid more than you have to pay, ask for a refund. If you cannot get a reduction or refund, or are not sure how much you owe, call the Plan at 1- 800/ 222- APWU for assistance.

1999 RI 71- 004 10

General Limitations continued

Physician services Claims for physician services provided for retired FEHB members age 65 and older who do not have Medicare Part B are also processed in accordance with 5 U. S. C. 8904( b). This law mandates the use of Medicare Part B limits for covered physician services for those members who are not covered by Medicare Part B.

The Plan is required to base its payment on the Medicare- approved amount (which is the Medicare fee schedule for the service), or the actual charge, whichever is lower. If your doctor is a member of the Plans preferred provider organization (PPO) and participates with Medicare, the Plan will base its payment on the lower of these two amounts and you are responsible only for any deductible and the PPO copayment or coinsurance.

If you go to a PPO doctor who does not participate with Medicare, you are responsible for any deductible and the copayment or coinsurance. In addition, unless the doctors agreement with the Carrier specifies otherwise, you must pay the difference between the Medicare- approved amount and the limiting charge (115% of the Medicare- approved amount).

If your physician is not a Plan PPO doctor that participates with Medicare, the Plan will base its regular benefit payment on the Medicare- approved amount. For instance, under this Plans surgery benefit, the Plan will pay 75% of the Medicare- approved amount. You will only be responsible for any deductible and coinsurance equal to 25% of the Medicare- approved amount.

If your physician does not participate with Medicare, the Plan will still base its payment on the Medicare- approved amount. However, in most cases you will be responsible for any deductible, the coinsurance or copayment amount, and any balance up to the limiting charge amount (115% of the Medicare- approved amount).

Since a physician who participates with Medicare is only permitted to bill you up to the Medicare fee schedule amount even if you do not have Medicare Part B, it is generally to your financial advantage to use a physician who participates with Medicare.

The Carriers explanation of benefits (EOB) will tell you how much the physician can charge you in addition to what the Plan paid. If you are billed more than the physician is allowed to charge, ask the physician to reduce the bill. If you have already paid more than you have to pay, ask for a refund. If you cannot get a reduction or refund, or are not sure how much you owe, call the Plan at 1- 800/ 222- APWU for assistance.

1999 RI 71- 004 11

General Exclusions

These exclusions apply to more than one or to all benefits categories. Exclusions that are primarily identified with a single benefit category are listed along with that benefit category, but may apply to other categories. Therefore, please refer to the specific benefit sections as well to assure that you are aware of all benefit exclusions.

Benefits are provided only for services and supplies that are medically necessary (see definition). The Carrier reserves the right to determine medical necessity. The fact that a covered provider has prescribed, recommended, or approved a service or supply does not, in itself, make it medically necessary.

Benefits will not be paid for services and supplies when:

No charge would be made if the covered individual had no health insurance coverage

Furnished without charge (except as described on page 9); while in active military service; or required for illness or injury sustained on or after the effective date of enrollment (1) as a result of an act of war within the United States, its territories, or possessions or (2) during combat

Furnished by immediate relatives or household members, such as spouse, parent, child, brother, or sister by blood, marriage, or adoption

Furnished or billed by a provider or facility that has been barred from the FEHB Program

Furnished or billed by a noncovered facility, except that medically necessary prescription drugs and physical, speech and occupational therapy rendered by a qualified professional therapist on an outpatient basis are covered subject to plan limits

For or related to sex transformation, sexual dysfunction or sexual inadequacy except for organic impotence as shown on pages 13 and 23

Not specifically listed as covered

Investigational or experimental (see pages 37 and 38)

Not provided in accordance with accepted professional medical standards in the United States

Furnished or billed by someone other than a covered provider as defined on page 6

Incurred while not covered by the Plan

Benefits will not be paid for:

Any portion of a provider's fee or charge ordinarily due from the enrollee but that has been waived. If a provider routinely waives (does not require the enrollee to pay) a deductible, copay or coinsurance, the Carrier will calculate the actual provider fee or charge by reducing the fee or charge by the amount waived

Charges the enrollee or Plan has no legal obligation to pay, such as excess charges for an annuitant age 65 or older who is not covered by Medicare Parts A and/ or B (see page 9 ), doctor charges exceeding the amount specified by the Department of Health and Human Services when benefits are payable under Medicare (limiting charge) (see page 10), or State premium taxes however applied

Procedures, services, drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest

Biofeedback; nonmedical self care or self help training, such as recreational, educational, or milieu therapy

Charges that the Plan determines to be in excess of the reasonable and customary charge

1999 RI 71- 004 12

Benefits

Inpatient Hospital Benefits What is covered The Plan pays for inpatient hospital services as shown below.

Precertification The medical necessity of your hospital admission must be precertified for you to receive full Plan benefits. Emergency admissions not precertified must be reported within 48 hours of admission even if you have been discharged. Otherwise, the benefits payable will be reduced by $500. See pages 30 and 31 for details.

Waiver This precertification requirement does not apply to persons whose primary coverage is another health insurance policy or when the hospital admission is outside the United States and Puerto Rico. Also, this requirement generally does not apply to persons whose primary coverage is Medicare Part A, however, see page 30 for exceptions. For information on when Medicare is primary, see pages 31, 32 and 33.

Room and board Benefits for hospital room and board and other hospital expenses for a bed patient (inpatient) in a hospital, include:

Ward and semiprivate accommodations.

Intensive care accommodations, when medically appropriate.

Isolation care accommodations, when medically appropriate to prevent contagion.

Lab, X- ray and pharmacy services.

Anesthesia supplies, operating and recovery room.

Professional ambulance service, when medically appropriate.

Blood or blood plasma, if not donated or replaced.

PPO benefit Plan pays room and board and Other charges at 90% of hospitals negotiated rates.

Non- PPO benefit After a $200 deductible per admission, Plan pays room and board and Other charges at 70% of

reasonable and customary charges.

Private room If a private room is used other than for isolation care, the hospital's average charge for semiprivate accommodations will be paid. If the hospital only has private rooms, the average semiprivate rate for comparable hospitals in the area will be allowed.

Related benefits Pre- surgical testing Outpatient laboratory tests, pathology, radiology and X- rays related to surgery are paid as Other

Medical Benefits (see pages 19, 20 and 21).

Professional charges Charges for professional services of a doctor, alternate provider or anesthesiologist, even though billed by a hospital as part of hospital services, are covered only as shown on pages 13, 14, 15 and 19.

Take- home items Appliances, medical equipment and medical supplies that are provided for use outside a hospital are covered as Other Medical Benefits as shown on page 19. Prescription drugs and medicines dispensed for take- home use are covered as Prescription Drugs as shown on pages 23 and 24.

1999 RI 71- 004 13

Inpatient Hospital Benefits continued

Hospitalization for dental work The Plan pays for room and board and other hospital services for hospitalization in connection with

dental procedures only when a nondental physical impairment exists which makes hospitalization necessary to safeguard the health of the patient.

What is not covered A hospital admission that the Carrier determines is not medically appropriate, i. e., the medical services did not require the acute hospital inpatient (overnight) setting, but could have been provided in a doctor's office, the outpatient department of a hospital, or some other less expensive setting without adversely affecting the patient's condition or the quality of medical care.

Custodial care as defined on page 37.

Day and evening care centers, nursing homes, skilled nursing facilities, extended care and residential treatment facilities, a place for rest or for the aged, or any other place which does not meet the definition of a hospital as shown on page 5.

Services of a private duty nurse that would normally be provided by hospital nursing staff.

Personal comfort items such as radio, television, air conditioners, beauty and barber services, guest meals and beds.

The non- PPO benefits are the standard benefits of this plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non- PPO benefits apply.

Surgical Benefits What is covered The Plan pays for the following services:

PPO benefit After the $250 calendar year deductible, 90% of the surgeon's negotiated fee for the inpatient or outpatient surgical procedure.

Non- PPO benefit After satisfaction of the $250 calendar year deductible; 70% of reasonable and customary charges.

This Plan will pay charges in or out of a hospital, to the extent shown above, for:

Charges of a surgeon. Charges for normal postoperative care by the surgeon( s) are considered to be part of the surgical charges.

Charges of an anesthesiologist.

Voluntary sterilization procedures.

Routine circumcision of newborn.

Recognized surgery for morbid obesity and organic impotence (only with prior Plan approval.)

To obtain prior Plan approval, call Spectera/ CARE Programs at 1- 800/ 580- 8771.

Cosmetic surgery only if necessary: - for breast reconstruction following a mastectomy; or - for the correction of congenital defects which existed at or from birth (limited to conditions

listed on page 37); or - for repair of injuries caused by an accident provided the surgery is completed within two years

of the accidental injury.

Multiple surgical procedures When multiple or bilateral surgical procedures that add time or complexity to patient care are performed during the same operative session, the Plan pays 50% of the value of the secondary, lesser or repeat procedure( s).

1999 RI 71- 004 14

Surgical Benefits continued

Incidental procedures Only the value of the major procedure is allowed when an incidental procedure is performed through the same incision or when an independent procedure is carried out as an integral part of the total service.

Assistant surgeon (inpatient/ outpatient)

The Plan will consider 20% of the surgical allowance to be reasonable and customary for all assistant surgeons combined during the same operative session.

Second opinion (voluntary) See Other Medical Benefits (page 19).

Anesthesia Plan allowance is based upon CPT code value multiplied by units of time.

Organ/ tissue transplants and donor expenses

Transplant surgery means transfer of body organ( s) from the donor to the recipient (allogeneic) or a bone marrow transplant in which the donor and recipient are the same person (autologous). Donor means a person who undergoes a surgical operation for the purpose of donating a body organ( s) for transplant surgery. Recipient means a person insured by the Plan who undergoes a surgical operation to receive a body organ transplant.

Prior approval The Plan participates in a National Transplant Program administered by First Health. Before your

initial evaluation as a potential candidate for a transplant procedure, you or your doctor must contact First Health at 1- 800/ 447- 1704 and ask to speak to a Transplant Case Manager. You will be provided with information about this program and about transplant preferred providers.

The Plan pays reasonable and customary charges for a covered surgical transplant the same as expenses for any other illness or injury as follows (this benefit applies only if recipient is covered by the Plan):

PPO benefit All reasonable and customary charges for services performed by a provider, specified by the Plan for this benefit, whether incurred by the recipient or donor. If you participate in the National Transplant Program, you may receive prior approval for travel and lodging costs.

Non- PPO benefit Pretransplant evaluation, organ procurement, inpatient hospital, surgical and medical expenses for covered transplants, whether incurred by the recipient or donor, are limited to a maximum of $100,000 for each listed transplant, including multiple organ transplants.

What is covered Benefits will be provided for the following transplants:

Cornea, kidney, pancreas and liver.

Heart and heart/ lung.

Single or double lung transplants for the following end- stage pulmonary diseases at an approved center: primary fibrosis, primary hypertension, and emphysema; double- lung transplant for cystic fibrosis at an approved center.

Benefits for allogeneic bone marrow transplants are limited to patients with leukemia, advanced Hodgkins lymphoma, advanced non- Hodgkins lymphoma, aplastic anemia, severe combined immuno- deficiency disease or Wiskott- Aldrich syndrome.

Benefits for autologous bone marrow transplants and autologous peripheral stem cell support are limited to patients with acute leukemia in remission, relapsed non- Hodgkins lymphomas responding to treatment, resistant or recurrent neuroblastoma, relapsed Hodgkins disease responding to treatment, testicular cancer, mediastinal cancer, retroperitoneal cancer, ovarian germ cell tumors, epithelial ovarian cancer, breast cancer and multiple myeloma.

Related medical and hospital expenses of the donor are covered when the recipient is covered by the Plan.

1999 RI 71- 004 15

Surgical Benefits continued

What is not covered Transplants not listed as covered.

Surgical implant of artificial hearts.

Services or supplies for, or related to, surgical transplant procedures for artificial or human organ transplants not listed as specifically covered. Related services include administration of high dose chemotherapy when supported by autologous bone marrow transplant.

Oral and maxillofacial surgery

This Plan will pay reasonable and customary charges in or out of a hospital, to the extent shown on page 13, only for:

Extraction of impacted (unerupted) teeth.

Alveoplasty, partial ostectomy and radical resection of mandible with bone graft unrelated to tooth structure.

Fractures of the jaw and/ or facial bones and severe malocclusion (protruding or retruding mandible or maxilla) caused by accidental injury.

Correction of cleft palate and severe malocclusion if caused by congenital malformation.

Excision of bony cysts of the jaw unrelated to tooth structure.

Excision of tori, tumors, leukoplakia, premalignant and malignant lesions, and biopsy of hard and soft oral tissues.

Reduction of dislocations and excision, manipulation, arthrocentesis, aspiration or injection of temporomandibular joints.

Removal of foreign body, skin, subcutaneous alveolar tissue, reaction- producing foreign bodies in the musculoskeletal system and salivary stones.

Incision/ excision of salivary glands and ducts.

Repair of traumatic wounds.

Sinusotomy, including repair of oroantral and oromaxillary fistula and/ or root recovery.

Surgical treatment of trigeminal neuralgia.

Frenectomy or frenotomy, skin graft or vestibuloplasty- stomatoplasty unrelated to periodontal disease.

Incision and drainage of cellulitis unrelated to tooth structure. To determine whether a procedure is covered, it is suggested that prior Carrier approval be obtained by calling 1- 800/ 222- APWU.

Mastectomy Surgery Women who undergo mastectomies may, at their option, have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure.

Pre- surgical testing Outpatient laboratory tests, pathology, radiology and X- rays related to surgery are paid as Other Medical Benefits (see pages 19 and 20).

What is not covered Cosmetic surgery and other related expenses, except as described on page 13.

Sterilization reversal.

Trimming of toenails or removal of corns and calluses**, except when the patient is under active treatment of metabolic or peripheral vascular disease.

Eye surgery, such as radial keratotomy, when the primary purpose is to correct myopia (nearsightedness), hyperopia (farsightedness) or astigmatism (blurring).

Dental bridges, replacement of natural teeth, dental/ orthodontic/ temporomandibular joint dysfunction appliances and any related expenses.

Treatment of periodontal disease and gingival tissues, and abscesses.

Charges related to orthodontic treatment.

Oral implants or transplants of any kind. ** May be eligible for Wellness benefit (see page 22).

The non- PPO benefits are the standard benefits of this plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non- PPO benefits apply.

1999 RI 71- 004 16

Maternity Benefits What is covered The Plan pays the same benefits for hospital, surgery (delivery), laboratory tests and other medical

expenses as for illness or injury. The mother, at her option, may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a caesarean delivery. Inpatient stays will be extended if medically necessary.

Inpatient hospital Precertification The medical necessity of your hospital admission must be precertified for you to receive full Plan

benefits. Unscheduled or emergency admissions not precertified must be reported within 48 hours of admission even if you have been discharged. Newborn confinements that extend beyond the mother's discharge must also be precertified. If any of the above are not done, the benefits payable will be reduced by $500. See pages 30 and 31 for details.

Waiver This does not apply when the hospital admission is outside the United States and Puerto Rico.

Room and board and Other charges

Benefits for hospital room and board and other hospital expenses for a bed patient (inpatient) in a hospital, include:

Ward and semiprivate accommodations.

Intensive care accommodations, when medically appropriate.

Isolation care accommodations, when medically appropriate to prevent contagion.

Lab, X- ray and pharmacy services.

Anesthesia supplies, operating and recovery room.

Professional ambulance service, when medically appropriate.

Blood or blood plasma, if not donated or replaced.

PPO benefit Plan pays room and board and Other charges at 90% of hospitals negotiated rates.

Non- PPO benefit After a $200 deductible per admission, Plan pays room and board and Other charges at 70% of reasonable and customary charges.

Bassinet and nursery Hospital charges for bassinet and nursery care of the child during the mother's hospital confinement are considered expenses of the mother and not expenses of the child. Any other expenses incurred by the child will be considered the child's own and will be allowed only if the child is covered by a Self and Family enrollment.

Outpatient care Outpatient hospital care for surgery (delivery) including care in freestanding ambulatory facilities, including birthing centers, is covered as described under Other Medical Benefits on pages 19 and 20.

Obstetrical care Delivery (paid under Surgical Benefits as shown on page 13), including prenatal and postpartum care (paid as shown on pages 19 and 20).

Administration of anesthesia, as shown on page 14.

Services of a licensed midwife.

Tests Sonograms, amniocentesis (but not for diagnosing multiple births) and other related diagnostic services which are accepted medical practice, paid as shown on pages 19 and 20.

1999 RI 71- 004 17

Maternity Benefits continued

Related benefits Contraceptive devices and drugs

See Other Medical Benefits on page 19 and Prescription Drugs on pages 23 and 24.

Diagnosis and treatment of infertility

Diagnosis and treatment of infertility will be covered up to a maximum Plan benefit of $2,500 per member per calendar year.

Voluntary sterilization See Surgical Benefits on page 13.

Well child care See Additional Benefits on page 22.

For whom Benefits are payable under Self Only enrollments and for family members under Self and Family enrollments.

What is not covered Assisted Reproductive Technology (ART) procedures such as artificial insemination, in vitro fertilization, embryo transfer and GIFT, as well as services and supplies related to ART procedures are not covered.

Reversal of voluntary surgical sterilization.

Charges related to abortions except when life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest.

The non- PPO benefits are the standard benefits of this plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non- PPO benefits apply.

1999 RI 71- 004 18

Mental Conditions/ Substance Abuse Benefits What is covered The Plan pays for the following Mental conditions/ substance abuse services:

Inpatient care Plan pays for ward or semiprivate accommodations, other hospital charges and professional fees. In lieu of medically appropriate inpatient care, and with prior Plan approval, coverage includes treatment at a licensed day treatment facility which has been accredited by the Joint Commission on Accreditation of Healthcare Organizations. Prior Plan approval may be obtained by calling

ValueOptions toll- free at 1- 888/ 700- 7965.

Outpatient care Plan pays for outpatient services by doctors and other covered practitioners for the treatment of mental conditions or substance abuse.

PPO benefit After a $250 annual deductible per person, the Plan pays:

Inpatient Care - 60% of providers negotiated fees for up to 45 days per person each calendar year. Outpatient Care - 70% of providers negotiated fees for up to 30 visits per person each calendar year.

Non- PPO benefit After a $750 annual deductible per person, the Plan pays:

Inpatient Care - 50% of reasonable and customary charges up to 30 days per person each calendar year. Outpatient Care - 50% of reasonable and customary charges up to 15 visits per person each calendar year.

Benefit limitations Annual maximum The specified limits on covered inpatient days are inclusive of any and all days previously used

during the year regardless of whether the days were in a PPO or non- PPO facility. The specified limits on covered outpatient visits are inclusive of any and all visits previously used during the year regardless of whether the visits were with a PPO or non- PPO provider.

Lifetime maximum The maximum lifetime benefit for inpatient treatment of alcoholism and/ or drug abuse is one treatment program per member, not to exceed a maximum Plan payment of $3,000.

Precertification- Inpatient care The medical necessity of your admission to a hospital or other facility must be precertified at least 48 hours prior to admission for you to receive full Plan benefits. Emergency admissions must be reported within 48 hours of admission even if you have been discharged. Otherwise, the benefits will be reduced by $500. To precertify an admission for mental conditions/ substance abuse; you, your representative, your doctor or your hospital must call ValueOptions toll- free at 1- 888/ 700- 7965.

Preauthorization- Outpatient care Outpatient care for mental conditions/ substance abuse requires prior Plan approval. Prior approval must be obtained by calling ValueOptions toll- free at 1- 888/ 700- 7965 prior to seeking care.

What is not covered Treatment for learning disabilities and mental retardation.

Services rendered or billed by a school or halfway house or a member of its staff.

Services and supplies that are not medically appropriate.

Phototherapy for treatment of Seasonal Affective Disorder (SAD).

The non- PPO benefits are the standard benefits of this plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non- PPO benefits apply.

1999 RI 71- 004 19

Other Medical Benefits What is covered

Outpatient physician visits Coverage for home or office visits, outpatient consultations and second surgical opinions are covered as follows:

PPO benefit Plan pays in full after a $15 copayment for each covered outpatient visit charge. The $250 deductible does not apply to this benefit.

Non- PPO benefit After the $250 calendar year deductible, the Plan pays 70% of reasonable and customary charges.

Chiropractic treatment Benefits are limited to 12 chiropractic visits and/ or manipulations per person each calendar year.

Other services PPO benefit After the $250 calendar year deductible, 90% of provider's negotiated fees.

Non- PPO benefit After the $250 calendar year deductible, the Plan pays 70% of reasonable and customary charges. Coverage is provided for the following services when prescribed by a doctor:

Hospital visits and inpatient consultations.

Diagnostic services such as X- rays, electrocardiograms, laboratory tests, allergy tests and preadmission testing.

Durable medical equipment (as defined on page 37), such as a wheelchair, kidney machine and oxygen, rented or purchased at the Plan's option.*

Established outpatient cardiac and pulmonary rehabilitation programs.

Radiation therapy.

Chemotherapy for cancer.

Renal dialysis.

Necessary supplies and accessories for use in connection with home dialysis, hyperalimentation and intravenous therapy.*

Artificial limbs, joints and eyes; pacemakers; and leg, arm, neck, and back braces; but not replacement, adjustment, or repair of braces, unless replacement is necessary due to the growth of a child.*

Stump hose for artificial limbs.

Internal (implant) and the first external breast prosthesis, and the first bra for use with the external prosthesis following mastectomy.

Internal (implant) ocular lenses and/ or the first contact lenses required to correct an impairment caused by trauma or disease. The services of an optometrist are limited to the testing, evaluation and fitting of the first contact lenses required to correct an impairment caused by trauma or disease.

Catheters, permanent tracheotomy tubes, ostomy bags and supplies and accessories required for attachment.*

Intra- uterine devices (including the cost of insertion and removal). * The Plan recommends that prior approval be obtained for these services and supplies. To obtain

prior Carrier approval, call Spectera/ CARE Programs at 1- 800/ 580- 8771.

1999 RI 71- 004 20

Other Medical Benefits continued

Home health care and rehabilitative therapy

These benefits must be provided under a treatment plan prescribed by a doctor and require prior Carrier approval. To obtain prior Plan approval, call Spectera/ CARE Programs at 1- 800/ 580- 8771.

Professional private duty intermittent nursing care performed during home visits by a Registered Nurse (R. N.), Licensed Practical Nurse (L. P. N.), or Licensed Vocational Nurse (L. V. N.), up to a maximum Plan payment of $90 per day. The patient must have specific needs for which only an R. N., L. P. N., or L. V. N. can provide the necessary services.

Professional services of a licensed registered therapist performing rehabilitative physical, occupational and speech therapy. These services may be provided in an outpatient setting or in the patients home.

Outpatient hospital services Outpatient services and supplies of a hospital or free- standing ambulatory facility the day of a surgical procedure (including change of cast), hemophilia treatment, hyperalimentation, rabies shots, cast or suture removal, oral surgery, dental and foot treatment, chemotherapy for treatment of cancer, and radiation therapy.

Medical emergency Outpatient services and supplies of a hospital or free- standing ambulatory facility are covered for treatment within 24 hours after onset of a true medical emergency. For Plan purposes, a medical emergency is the sudden and unexpected onset of a serious, possibly life- threatening condition requiring immediate care such as loss of consciousness, loss of breathing, poisoning, severe bleeding or chest pain. If you are unsure of the severity of a condition in terms of this benefit, the Plan recommends that you first call its 24- hour nurse advisory service (1- 800/ 755- 2200) or your physician.

The following conditions are not generally considered medical emergencies for purposes of this Plan:

Colds, earaches, sore throats, flu

Nausea and headaches

Maternity/ term deliveries If you use an emergency room for other than a recognized medical emergency, facility fees and supplies will not be covered.

Preventive services In addition to coverage of diagnostic X- ray, laboratory and pathology services and machine diagnostic tests, the following routine (screening) services are covered as preventive care:

Breast cancer screening Mammograms are covered for women age 35 and older as follows:

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

From age 40 through 49, one mammogram screening every one or two consecutive calendar years

From age 50 through 64, one mammogram screening every calendar year

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

Cervical cancer screening Annual coverage of one pap smear for women age 18 and older

Colorectal cancer screening Annual coverage of one fecal occult blood test for members age 40 and older

Prostate cancer screening Annual coverage of one PSA (Prostate Specific Antigen) test for men age 40 and older

Nonfasting total blood cholesterol test

Covered once annually per covered person from age 19 through 64 years old

1999 RI 71- 004 21

Other Medical Benefits continued

Tetanus diphtheria (Td) booster

Covered once every 10 years per covered member or spouse age 19 years and over. (For dependent children through age 22, see Childhood immunizations below.)

Influenza and Pneumococcal vaccines

Covered once annually per covered person age 65 years and over

Limited benefits Childhood immunizations Childhood immunizations recommended by the American Academy of Pediatrics are covered for

eligible members under age 22.

Smoking cessation benefit After satisfaction of the calendar year deductible, the Plan will pay up to $100 for enrollment in one smoking cessation program per member per lifetime.

What is not covered Routine physical examinations, routine eye examinations, and immunizations.**

Eyeglasses, contact lenses except as shown above, eye exercises and visual training.**

Hearing aids and examinations for them.**

Professional fees for automated lab tests.

Weight reduction/ control and treatment of obesity not caused by an organic condition except as shown on page 13.**

Orthopedic shoes, foot appliances or any related expenses, elastic stockings, corsets; lumbosacral, neck or joint supports; trusses, air purifiers, whirlpool equipment, sun and heat lamps, light boxes, heating pads, exercise devices, stair glides and elevators.

Drugs and medicines that can be purchased without a doctors prescription, even if a doctor has prescribed them or recommended their use.

Nursing services and rehabilitative therapy without prior Plan approval.

Speech therapy for developmental delay.

Services of nurses aides or home health aides.

Administration of high dose chemotherapy when supported by non- covered autologous bone marrow transplants.

Maintenance therapies. ** May be eligible for Wellness benefit (see page 22).

The non- PPO benefits are the standard benefits of this plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non- PPO benefits apply.

1999 RI 71- 004 22

Additional Benefits

The additional benefits described on this page are not subject to any deductibles.

Accidental injury The Plan pays as follows for outpatient first aid treatment within 24 hours after an accidental injury (an injury resulting from a violent external force). There is no deductible for first aid treatment for an accidental injury rendered within 24 hours after the injury.

PPO benefit 100% of provider's negotiated fees.

Non- PPO benefit 100% of reasonable and customary charges.

24- hour nurse advisory The Plan offers a 24- hour nurse advisory service for your use. This program is strictly voluntary and confidential. You may call toll- free at 1- 800/ 755- 2200 and reach registered nurses to discuss an existing medical concern or to receive information about numerous health care issues.

Hospice care The Plan pays reasonable and customary charges for hospice care provided by a hospice program subject to the following annual limits:

Maximum annual outpatient benefit................................................................................$ 3,000

Maximum annual inpatient benefit .................................................................................$ 2,000

Maximum bereavement benefit per family unit during any one calendar year.....................$ 200 Conditions: 1) Patient's doctor certifies terminal illness and life expectancy of six months or less, and 2) the hospice in- or outpatient services must be ordered by the patient's doctor and charged for by an approved hospice program.

Preventive benefits The Plan pays for the following preventive benefits (see also Preventive services under Other Medical Benefits on pages 20 and 21):

Well child care The Plan pays for physical examinations and laboratory tests for children through age 12 covered by a Self and Family enrollment. The Plan also pays for one eye exam for amblyopia (lazy eye) and strabismus (eye muscle imbalance) per covered child between the ages of 2 through 6. Benefits provided are as follows:

PPO benefit 100% for children ages birth through 12.

Non- PPO benefit 100% of reasonable and customary charges not to exceed Plan maximum of $250 per child per year for children birth through age 3. For children ages 4 through 12, the Plan pays a maximum benefit of $150 per child per calendar year.

Childhood immunizations The Plan will cover childhood immunizations recommended by the American Academy of Pediatrics for dependent children under age 22 as follows:

PPO benefit 100% of provider's negotiated fees.

Non- PPO benefit 100% of reasonable and customary charges.

Wellness benefit The Plan reimburses up to $250 per Self Only enrollment and $350 per Self and Family enrollment per calendar year for non- covered expenses such as vision care, eyeglasses, hearing aids, if received in 1999 and no other benefits for 1999 have been paid. If the Plan paid claims of less than $350 for a Self and Family enrollment, the difference up to $350 will be paid. See page 27 for additional claims information.

Review and reward program Upon receipt of a corrected hospital billing from the member, the Plan will credit 20% of any hospital charge over $20 for covered services and supplies that were not actually provided to a covered person. The maximum amount payable under this program is $100 per person per calendar year.

The non- PPO benefits are the standard benefits of this plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non- PPO benefits apply.

1999 RI 71- 004 23

Prescription Drug Benefits What is covered You may purchase the following medications and supplies prescribed by a doctor from either a

pharmacy or by mail:

Drugs and medicines, including those for smoking cessation, for use at home that are obtainable only upon a doctor's prescription and listed in official formularies

Insulin and reagent strips for known diabetics

Needles and syringes for the administration of covered medications

Elective birth control methods limited to prescription birth control pills and prescription diaphragms

Approved drugs for organic impotence subject to prior Plan approval and limitations on dosage and quantity

What is not covered Medication that does not require a prescription under Federal law even if your doctor prescribes it or a prescription is required under your State law

Vitamins, minerals, nutritional supplements, and enteral formulas (liquid food supplements)

Medical supplies such as dressings and antiseptics

Drugs and supplies for cosmetic purposes

From a pharmacy Plan pharmacy After the $50 per person calendar year drug deductible (maximum $100 per family), the Plan pays

80% of covered charges. You may obtain up to a 30- day supply plus one 30- day refill for each prescription purchased from a Plan pharmacy. After one 30- day refill, you must obtain a new prescription and submit it to the Mail Order Program. Failure to do so will result in benefits payable at the non- Plan pharmacy benefit level and the waiver below will not apply. Refills for maintenance medications are not considered new prescriptions except when the doctor changes the strength or 180 days have elapsed since the previous purchase.

Call 1- 800/ 841- 2734 to locate a Plan network pharmacy in your area.

To use a Plan pharmacy, you must present an APWU/ PAID prescription identification card which the Plan will provide you.

You will be required to pay only your deductible and coinsurance for the drugs.

Do not submit a claim to the Plan. The Plan pharmacy will automatically submit your claim for you.

Waiver If you have Medicare Parts A and B as your primary payer and you use a Plan pharmacy, the Plan will waive the deductible and the coinsurance for purchase of generic drugs. For purchase of brand name drugs, only the deductible will be waived. This waiver does not apply beyond the first 30- day supply and the first 30- day refill of each prescription.

Non- Plan pharmacy If you do not use your identification card, if you elect to use a non- network pharmacy or if a Plan pharmacy is not available, you will need to file a claim and the Plan will reimburse you for covered expenses as follows:

After the $50 per person calendar year deductible (maximum $100 per family), the Plan pays 60%

of covered charges for up to a 30- day supply and unlimited refills.

Waiver If you have Medicare Parts A and B as your primary payer, the Plan will waive the deductible applicable to prescription drugs.

1999 RI 71- 004 24

Prescription Drug Benefits continued

To claim benefits Use a Prescription Drug Claim Form to claim benefits for prescription drugs and supplies you purchased from a non- Plan pharmacy. You may obtain forms by calling 1- 800/ 222- APWU. Your claim must include receipts that show the prescription number, National Drug Code (NDC) number, name of drug, prescribing doctor's name, date and charge. Follow the instructions on the claim form and mail to:

APWU Health Plan Post Office Box 967 Silver Spring, MD 20910

By mail If you are currently taking a prescription medication on a regular basis, the Mail order drug program can help you save money on the cost of your prescriptions and refills. Your doctor may prescribe up to a 90- day supply. Merck- Medco Rx Services, which is a licensed pharmacy, will fill your prescription within two weeks of receipt of a prescription received by mail or within two business days of a prescription initiated by physicians over the telephone.

The Plan pays 100% after a $7 copayment for covered generic drugs and medicines and a $25 copayment for covered brand name drugs when purchased through the Plans Mail order drug program. Charges for Mail order drugs are not subject to any deductible.

Waiver If you have Medicare Parts A and B as your primary payer, the Plan will waive the copayments applicable to prescription drugs obtained through the Mail order drug program. You do not need to make any payment or submit a claim for Mail order drugs.

To claim benefits Contact the Plan for an order kit and the address of the Mail order drug program. To use the program: 1) Complete the Patient Profile Questionnaire and complete the information on the back of the preaddressed envelope. 2) Enclose your prescription and mail to Merck- Medco, who will fill your prescription and mail it

to you. 3) Merck- Medco will file your claim with the Plan, then bill you for any outstanding balance. Do

not submit a claim to the Plan for mail order drugs. 4) Forms necessary for refills and future prescription orders will be provided each time you receive

a supply of medication from the program. If you have any questions about the Mail order drug program or about a particular drug or prescription, you may call toll- free: 1- 800/ 841- 2734.

Purchasing mail order drugs overseas

Use of the Mail order drug program for overseas delivery is restricted to delivery to APO boxes. The prescribing doctor must be licensed to prescribe drugs in the United States.

Drugs from other sources Prescription drugs and antigens for treatment of allergies provided to you by a doctor or facility are covered as Prescription Drugs as shown on pages 23 and 24.

The non- PPO benefits are the standard benefits of this plan. PPO benefits apply only when you use a PPO provider. When no PPO provider is available, non- PPO benefits apply.

Dental Benefits What is covered The services listed under the dental benefits are a complete list of covered services for which the

Plan pays the following:

Routine dental care Diagnostic and preventive services up to $25 a visit (up to two [2] visits each year), including examinations, prophylaxis (cleaning), X- rays of all types and fluoride treatment.

Restorative dentistry (fillings): one surface $13; two or more surfaces $18.

Simple extractions: $13 per tooth.

Restorative care.

1999 RI 71- 004 25

Dental Benefits continued

Restorative care There is no limit to the number of fillings or simple extractions in a calendar year.

ADA code Amalgam restorations (including polishing)

2110 Amalgam- one surface .........................................................................................$ 13 2120 Amalgam- two surfaces .......................................................................................$ 18 2130 Amalgam- three surfaces .....................................................................................$ 18 2131 Amalgam- four surfaces.......................................................................................$ 18 2140 Amalgam- one surface .........................................................................................$ 13 2150 Amalgam- two surfaces .......................................................................................$ 18 2160 Amalgam- three surfaces .....................................................................................$ 18 2161 Amalgam- four surfaces.......................................................................................$ 18

Silicate restoration

2210 Silicate cement per restoration ............................................................................$ 13

Acrylic or plastic or composite resin

2330 Acrylic or plastic or composite resin- one surface................................................ $13 2331 Acrylic or plastic or composite resin- two surfaces .............................................. $18 2332 Acrylic or plastic or composite resin- three surfaces ............................................ $18 2335 Acrylic or plastic or composite resin- involving incisal angle or four or more

surfaces.............................................................................................................. $18

Acrylic or plastic or composite resin

2380 Resin- one surface, posterior- primary .................................................................. $13 2381 Resin- two surfaces, posterior- primary................................................................. $18 2382 Resin- three or more surfaces, posterior- primary.................................................. $18 2385 Resin- one surface, posterior- permanent .............................................................. $13 2386 Resin- two surfaces, posterior- permanent............................................................. $18 2387 Resin- three or more surfaces, posterior- permanent ............................................. $18

Gold foil restorations

2410 Gold foil- one surface .......................................................................................... $13 2420 Gold foil- two surfaces......................................................................................... $18 2430 Gold foil- three surfaces....................................................................................... $18

Gold inlay restorations

2510 Gold inlay- one surface........................................................................................ $13 2520 Gold inlay- two surfaces ...................................................................................... $18 2530 Gold inlay- three surfaces .................................................................................... $18

Porcelain restorations

2610 Porcelain inlay- one surface................................................................................. $13 2620 Porcelain inlay- two surfaces ............................................................................... $18 2630 Porcelain inlay- three surfaces ............................................................................. $18 2650 Inlay- Composite/ Resin- one surface..................................................................... $13 2651 Inlay- Composite/ Resin- two surfaces ................................................................... $18 2652 Inlay- Composite/ Resin- three or more surfaces .................................................... $18

Extractions ADA code Simple extractions (includes local anesthesia and post- operative care)

7110 Single tooth ........................................................................................................ $13 7120 Each additional tooth.......................................................................................... $13 7210 Surgical extractions (each) ................................................................................. $13

Related benefits Accidental injury to natural teeth

The Plan will pay for covered expenses to the same extent as expenses for any other illness or injury for necessary repair of accidental injury to natural teeth due to a blow or fall, including dental X- rays, provided the treatment is performed within two years of the accident and while the patient is still covered by the Plan.

Oral and maxillofacial surgery

For covered oral surgery, see page 15 .

1999 RI 71- 004 26

Dental Benefits continued

What is not covered Services not shown as covered under this benefit.

Dental bridges, replacement of natural teeth, dental/ orthodontic/ temporomandibular joint dysfunction appliances and any related expenses.

Treatment of periodontal disease and gingival tissues, and abscesses.

Charges related to orthodontic treatment.

Oral implants or transplants of any kind.

How to Claim Benefits Claim forms, identification cards and questions

If you do not receive your identification card( s) within 60 days after the effective date of your enrollment, call the Carrier at 1- 800/ 222- APWU; for TDD, use 1- 800/ 622- 2511 to report the delay. In the meantime, use your copy of the SF 2809 enrollment form or your annuitant confirmation letter from OPM as proof of enrollment when you obtain services. This is also the number to call for claim forms or advice on filing claims.

If you made your open season change by using Employee Express and have not received your new ID card by the effective date of your enrollment, call the Employee Express HELP number to request a confirmation letter. Use that letter to confirm your new coverage with providers.

If you have a question concerning Plan benefits, contact the Carrier at 800/ 222- APWU or you may write to the Carrier at PO Box 3279, Silver Spring, MD 20918. You may also contact the Carrier by fax at 301/ 622- 5712, at its website at http:// www. apwuhp. com or by email at custser@ apwuhp. com.

How to file claims Claims filed by your doctor that include an assignment of benefits to the doctor are to be filed on the form HCFA- 1500, Health Insurance Claim Form. Claims submitted by enrollees may be submitted on the HCFA- 1500 or a claim form that includes the information shown below. Bills and receipts should be itemized and show:

Name of patient and relationship to enrollee

Plan identification number of the enrollee

Name, address and taxpayer identification number of person or firm providing the service or supply

Dates that services or supplies were furnished

Type of each service or supply and the charge

Diagnosis In addition:

A copy of the explanation of benefits (EOB) from any primary payer (such as Medicare) must be sent with your claim.

Bills for private duty nurses must show that the nurse is a registered, licensed practical or licensed vocational nurse.

Claims for rental or purchase of durable medical equipment, private duty nursing, and physical, occupational and speech therapy require a written statement from the doctor specifying the medical necessity for the service or supply and the length of time needed.

Claims for prescription drugs that are not obtained from a Plan pharmacy or through the Mail order program must include receipts that include the prescription number, the National Drug Code (NDC) number, name of drug, prescribing doctor's name, date and charge.

Claims for overseas (foreign) services should include an English translation. Charges should be converted to U. S. dollars using the exchange rate applicable at the time the expense was incurred.

Cancelled checks, cash register receipts or balance due statements are not acceptable.

1999 RI 71- 004 27

How to Claim Benefits continued

How to file claims (continued)

After completing a claim form and attaching proper documentation, send claims to: APWU Health Plan Post Office Box 967 Silver Spring, MD 20910 Phone: 1- 800/ 580- 8771 (for hospital precertification - see page 30) Phone: 1- 800/ 222- APWU (benefits verifications) Phone: 1- 301/ 622- 1700 (other business) FAX: 1- 301/ 622- 5712 (not for filing of claims) TDD line for hearing- impaired: 1- 800/ 622- 2511 (TDD equipment required)

Wellness Claims The Plan notifies members in November of each year if they are eligible for the Wellness benefit. Submit Wellness claims after January 1, 2000. Wellness claims are paid after March 1, 2000. If, after Wellness benefits have been paid, subsequent claims are received for hospital, medical or dental expenses, payments made under the Wellness benefit will be deducted from allowable charges.

Records Keep a separate record of the medical expenses of each covered family member as deductibles and maximum allowances apply separately to each person. Save copies of all medical bills, including those you accumulate to satisfy a deductible. In most instances, they will serve as evidence of your claim. The Carrier will not provide duplicate or year end statements.

Submit claims promptly Claims must be submitted within two years of the date you incur the expense. The Plan encourages timely submission because failure to file within the two- year limit will invalidate your claim, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible. Once benefits have been paid, there is a three year limitation on the reissuance of uncashed checks.

Overseas claims See Records and How to file claims on pages 26 and 27.

Direct payment to hospital or provider of care

You or your spouse may authorize direct payment to the provider by completing the assignment of benefits payment section of the claim form or the provider's own assignment form. Otherwise, payment will be made to you. The Plan reserves the right to make payment of benefits directly to you.

When more information is needed

Reply promptly when the Carrier requests information in connection with a claim. If you do not respond, the Carrier may delay processing or limit the benefits available.

Confidentiality Medical and other information provided to the Carrier, including claim files, is kept confidential and will be used: 1) by the Carrier and its subcontractors for internal administration of the Plan,

coordination of benefit provisions with other plans, and subrogation of claims; 2) by law enforcement officials with authority to investigate and prosecute alleged civil or criminal actions; 3) by OPM to review a disputed claim or perform its contract administration functions; 4) by OPM and the General Accounting Office when conducting audits as required by the FEHB law; or 5) for bona fide medical research or education. Medical data that does not identify individual members may be disclosed as a result of the bona fide medical research or education. As part of its administration of the prescription drug benefits, the Plan may disclose information about a members prescription drug utilization, including the names of prescribing physicians, to any treating physicians or dispensing pharmacies.

Disputed claims review Reconsideration If a claim for payment is denied by the Carrier, you must ask the Carrier, in writing and within six

months of the date of the denial, to reconsider its decision before you request a review by OPM. (This time limit may be extended if you show you were prevented by circumstances beyond your control from making your request within the time limit.) OPM will not review your request unless you demonstrate that you gave the Carrier an opportunity to reconsider your claim. Before you ask the Carrier to reconsider, you should first check with your provider or facility to be sure that the claim was filed correctly.

1999 RI 71- 004 28

How to Claim Benefits continued

Reconsideration (continued) For instance, did they use the correct procedure code for the service( s) performed (surgery, laboratory test, X- ray, office visit, etc.)? Indicate any complications of any surgical procedure( s) performed. Include copies of an operative or procedure report, or other documentation that supports your claim. Your written request to the Carrier must state why, based on specific benefit provisions in this brochure, you believe the denied claim for payment should have been paid. Within 30 days after receipt of your request for reconsideration, the Carrier must affirm the denial in writing to you, pay the claim, or request additional information that is reasonably necessary to make a determination. If the Carrier asks a provider for information it will send you a copy of this request at the same time. The Carrier has 30 days after receiving the information to give its decision. If this information is not supplied within 60 days, the Carrier will base its decision on the information it has on hand.

OPM review If the Carrier affirms its denial, you have the right to request a review by OPM to determine whether the Carriers actions are in accordance with the terms of its contract. You must request the review within 90 days after the date of the Carriers letter affirming its initial denial.

You may also ask OPM for a review if the Carrier fails to respond within 30 days of your written request for reconsideration or 30 days after you have supplied additional information to the Carrier. In this case, OPM must receive a request for review within 120 days of your request to the Carrier for reconsideration or of the date you were notified that the Carrier needed additional information, either from you or from your doctor or hospital.

This right is available only to you or the executor of a deceased claimant's estate. Providers, legal counsel, and other interested parties may act as your representative only with your specific written consent to pursue payment of the disputed claim. OPM must receive a copy of your written consent with their request for review. Your written request for an OPM review must state why, based on specific benefit provisions in this brochure, you believe the Carrier should have paid the denied claim. If the Carrier has reconsidered and denied more than one unrelated claim, clearly identify the documents for each claim.

Your request must include the following information or it will be returned by OPM:

A copy of your letter to the Carrier requesting reconsideration;

A copy of the Carriers reconsideration decision (if the Carrier failed to respond, provide instead (a) the date of your request to the Carrier, or (b) the dates the Carrier requested and you provided additional information to the Carrier);

Copies of documents that support your claim (such as doctors' letters, operative reports, bills, medical records, explanation of benefit (EOB) forms); and

Your daytime phone number. Medical documentation received from you or the Carrier during the review process becomes a permanent part of the disputed claim file, subject to the provisions of the Freedom of Information Act and the Privacy Act.

Send your request for review to: Office of Personnel Management, Office of Insurance Programs, Contracts Division II, P. O. Box 436, Washington, DC 20044.

You (or a person acting on your behalf) may not bring a lawsuit to recover benefits on a claim for treatment, services, supplies or drugs covered by this Plan until you have exhausted the OPM review procedure, established at section 890.105, title 5, Code of Federal Regulations (CFR). If OPM upholds the Carrier's decision on your claim, and you decide to bring a lawsuit based on the denial, the lawsuit must be brought no later than December 31 of the third year after the year in which the services or supplies upon which the claim is predicated were provided. Pursuant to section 890.107, title 5, CFR, such a lawsuit must be brought against the Office of Personnel Management in Federal court.

Federal law exclusively governs all claims for relief in a lawsuit that relates to this Plan's benefits or coverage or payments with respect to those benefits. Judicial action on such claims is limited to the record that was before OPM when it rendered its decision affirming the Carriers denial of the benefit. The recovery in such a suit is limited to the amount of benefits in dispute.

Privacy Act statement -- If you ask OPM to review a denial of a claim for payment or service, OPM is authorized by chapter 89 of title 5, U. S. C., to use the information collected from you and the Carrier to determine if the Carrier has acted properly in denying you the payment or service, and the information so collected may be disclosed to you and/ or the Carrier in support of OPM's decision on the disputed claim.

1999 RI 71- 004 29

Protection Against Catastrophic Costs Catastrophic protection For certain services with coinsurance, the Plan pays 100% of reasonable and customary charges for the

remainder of the calendar year after the calendar year deductible is met when out- of- pocket expenses for coinsurance in that calendar year exceed $3,500 for a Self Only enrollment or $3,500 for a Self and Family enrollment. Whether or not you use Preferred providers, the $250 individual deductible or the $500 family deductible must be satisfied before the Plan will pay benefits at 100%.

Preferred Providers When your eligible out- of- pocket expenses from using Preferred providers exceed $2,000 for a Self Only enrollment or $2,000 for a Self and Family enrollment, the Plan pays 100% of covered expenses for Preferred providers for the remainder of the calendar year.

Out- of- pocket expenses Out- of- pocket expenses for the purposes of this benefit are:

The 10% you pay for PPO Inpatient hospital charges, Surgical, Maternity and Other Medical Benefits;

The 30% you pay for non- PPO Inpatient hospital charges, Surgical, Maternity and Other Medical Benefits; and

The copayment of $15 for outpatient visits to PPO physicians (see page 19). The following cannot be included in the accumulation of out- of- pocket expenses:

Expenses in excess of reasonable and customary charges or maximum benefit limitations;

Expenses for mental conditions, substance abuse or dental care;

Any amounts you pay because benefits have been reduced for non- compliance with this Plan's cost containment requirements (see pages 5, 6, 7, 8, 30 and 31);

Covered expenses applied to the $250 calendar year deductible;

The $200 per admission deductible for non- PPO Inpatient hospital charges;

Expenses for prescription drugs;

Expenses incurred in excess of the $90 per day provided under home nursing care (see page 20); and

Expenses in excess of hospice care and preventive care maximums.

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 plans catastrophic protection benefit during the prior year will be covered by your old plan if they are for care you got in January before the effective date of your coverage in this Plan. If you have already met the covered out- of- pocket maximum expense level in full, your old plans catastrophic protection benefit will continue to apply until the effective date. 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 years 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. The old plan will pay these covered expenses according to this years benefits; benefit changes are effective on January 1.

Change in enrollment In case of a change of enrollment within the Plan (i. e., Self Only to Self and Family or Self and Family to Self Only), any benefits paid under the original enrollment will apply toward limitations in the subsequent enrollment during the remainder of the current calendar year. Similarly, deductibles satisfied under the original enrollment will be credited to the subsequent enrollment during the remainder of the current calendar year.

1999 RI 71- 004 30

Other Information

Information You Have A Right To Know

All carriers in the FEHB Program must provide certain information to you. If you have questions or need additional information, you can obtain it by calling the Carrier at 800/ 222- APWU or you may write the Carrier at PO Box 3279, Silver Spring, MD 20918. You may also contact the Carrier by fax at 301/ 622- 5712, at its website at http:// www. apwuhp. com or by email at custser@ apwuhp. com.

You are entitled to the following information:

The Plans 1997 Disenrollment rate was 14.2%

Spectera, Inc. is the major subcontractor performing hospital precertification and case management for the Plan and is accredited by American Accreditation HealthCare Commission/ URAC effective May 24, 1997. PreferredOne Management Company performs hospital precertification and case management for members in the State of Minnesota only and is also URAC accredited effective August 1, 1997.

The American Postal Workers Union Health Plan is a not- for- profit Voluntary Employees Beneficiary Association (VEBA) formed in 1972 as the result of a merger between four predecessor union plans.

The carrier meets applicable State and Federal licensing and accreditation requirements for fiscal solvency, confidentiality and transfer of medical records. Additional information is available from the Plan.

Precertification Precertify before admission Precertification is not a guarantee of benefit payments. Precertification of an inpatient admission is

a predetermination that, based on the information given, the admission meets the medical necessity requirements of the Plan. It is your responsibility to ensure that precertification is obtained. If precertification is not obtained and benefits are otherwise payable, benefits for the admission will be reduced by $500.

To precertify a scheduled admission:

You, your representative, your doctor, or your hospital must call Spectera/ CARE Programs at least 48 hours prior to admission. The toll- free number is 1- 800/ 580- 8771 and may be reached 24 hours every day. In Minnesota, call PreferredOne at 1- 800/ 451- 9597 to precertify. To precertify an admission for mental conditions/ substance abuse, see page 18.

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; name and phone number of admitting doctor.

The doctor and/ or hospital will be notified telephonically of the number of days of confinement approved initially for the care. Written confirmation of the Carriers certification decision will be sent to the patient, provider and facility. If the length of stay needs to be extended, follow the procedures below.

Need additional days? The CARE nurse reviewer will be in contact with the facility and/ or physician throughout your hospitalization. If any additional days are required, CARE will obtain clinical information to determine if these days are medically necessary.

If the admission is precertified but you remain confined beyond the number of days certified as medically necessary, the Plan will not pay for charges incurred on any extra days that are determined to not be medically necessary by the Carrier during the claim review.

1999 RI 71- 004 31

Precertification continued

You dont need to certify an admission when:

Medicare Part A, or another group health insurance policy, is the primary payer for the hospital confinement (see pages 31 and 32). Precertification is required; however, for members with Medicare Part A prior to the 60 th day of a Medicare benefit period, when Medicare hospital benefits are exhausted prior to using lifetime reserve days or if being admitted to a Department of Veterans Affairs or Department of Defense hospital.

You are confined in a hospital outside the United States and Puerto Rico.

Maternity or emergency admissions

When there is an unscheduled maternity admission or an emergency admission due to a condition that puts the patient's life in danger or could cause serious damage to bodily function, you, your representative, the doctor, or the hospital must telephone the applicable number listed above within 48 hours of admission, even if the patient has been discharged from the hospital. Otherwise, inpatient benefits otherwise payable for the admission will be reduced by $500.

Newborn confinements that extend beyond the mother's discharge date must also be certified. You, your representative, the doctor or hospital must request certification for the newborn's continued confinement within 48 hours of delivery/ birth.

Other considerations An early determination of need for confinement (precertification of the medical necessity of inpatient admission) is binding on the Carrier unless the Carrier is misled by the information given to it. After the claim is received, the Carrier will first determine whether the admission was precertified and then provide benefits according to all of the terms of this brochure.

If you do not precertify If precertification is not obtained at least 48 hours before admission to the hospital (or within 48 hours of a maternity or emergency admission or, in the case of a newborn, the mother's discharge), a

medical necessity determination will be made at the time the claim is filed. If the Carrier determines that the hospitalization was not medically necessary, the inpatient hospital benefits will not be paid. However, medical supplies and services determined to be medically necessary and otherwise payable on an outpatient basis will be paid under applicable outpatient benefits.

If the claim review determines that the admission was medically necessary, any benefits payable according to all of the terms of this brochure will be reduced by $500 for failing to have the admission precertified.

If the admission is determined to be medically necessary, but part of the length of stay was found not to be medically necessary, inpatient hospital benefits will not be paid for the portion of the confinement that was not medically necessary. However, medical services and supplies determined to be medically necessary and otherwise payable on an outpatient basis will be paid under applicable outpatient benefits.

This Plan and Medicare Coordinating benefits The following information applies only to enrollees and covered family members who are entitled to

benefits from both this Plan and Medicare. You must disclose information about Medicare coverage, including your enrollment in a Medicare prepaid plan, to this Carrier; this applies whether or not you file a claim under Medicare. You must also give this Carrier authorization to obtain information about benefits or services denied or paid by Medicare when they request it. It is also important that you inform the Carrier about other coverage you may have as this coverage may affect the primary/ secondary status of this Plan and Medicare (see pages 8 and 9).

This Plan covers most of the same kinds of expenses as Medicare Part A, hospital insurance, and Part B, medical insurance, except that Medicare does not cover prescription drugs.

The following rules apply to enrollees and their family members who are entitled to benefits from both an FEHB plan and Medicare.

This Plan is primary if: (1) You are age 65 or over, have Medicare Part A (or Parts A and B), and are employed by the Federal Government;

(2) Your covered spouse is age 65 or over and has Medicare Part A (or Parts A and B) and you are employed by the Federal Government;

1999 RI 71- 004 32

This Plan and Medicare continued

This Plan is primary if:

(continued)

(3) The patient (you or a covered family member) is within the first 30 months of eligibility to receive Medicare Part A benefits due to End Stage Renal Disease (ESRD) except when Medicare (based on age or disability) was the patient's primary payer on the day before he or she became eligible for Medicare Part A due to ESRD; or (4) The patient (you or a covered family member) is under age 65 and eligible for Medicare solely

on the basis of disability, and you are employed by the Federal Government. For purposes of this section, "employed by the Federal Government" means that you are eligible for FEHB coverage based on your current employment and that you do not hold an appointment described under Rule 6 of the following Medicare is primary section.

Medicare is primary if: (1) You are an annuitant age 65 or over, covered by Medicare Part A (or Parts A and B) and are not employed by the Federal Government;

(2) Your covered spouse is age 65 or over and has Medicare Part A (or Parts A and B) and you are not employed by the Federal Government;

(3) You are age 65 or over and (a) you are a Federal judge who retired under title 28, U. S. C., (b) you are a Tax Court judge who retired under Section 7447 of title 26, U. S. C., or (c) you are the covered spouse of a retired judge described in (a) or (b);

(4) You are an annuitant not employed by the Federal Government, and either you or a covered family member (who may or may not be employed by the Federal Government) is under age 65 and eligible for Medicare on the basis of disability;

(5) You are enrolled in Part B only, regardless of your employment status; (6) You are age 65 or over and employed by the Federal Government in an appointment that

excludes similarly appointed nonretired employees from FEHB coverage, and have Medicare Part A (or Parts A and B);

(7) You are a former Federal employee receiving workers compensation and the Office of Workers Compensation has determined that you are unable to return to duty;

(8) The patient (you or a covered family member) has completed the 30- month ESRD coordination period and is still eligible for Medicare due to ESRD; or

(9) The patient (you or a covered family member) becomes eligible for Medicare due to ESRD after Medicare assumed primary payer status for the patient under rules 1) through 7) above.

When Medicare is Primary When Medicare is primary, all or part of your Plan deductibles and coinsurance will be waived as follows:

Inpatient hospital benefits: If you are enrolled in Medicare Part A, the Plan will waive the deductible and coinsurance.

Surgical Benefits: If you are enrolled in Medicare Part B, the Plan will waive the deductible and coinsurance for services covered by Medicare Part B.

Mental conditions/ substance abuse benefits: If you are enrolled in Medicare Part A, the Plan will waive the coinsurance applicable to inpatient hospital charges for services covered by Medicare Part A and this Plan. If you are enrolled in Medicare Part B, the Plan will waive the deductible and coinsurance for services covered by Medicare Part B.

Other Medical Benefits: If you are enrolled in Medicare Part B, the Plan will waive the deductible and coinsurance for services covered by Medicare Part B.

Prescription Drugs: If you are enrolled in Medicare Parts A and B where Medicare is the primary payer, the Plan will waive the coinsurance and deductible applicable to generic prescription drugs (but will waive only the deductible for brand name drugs) obtained from a Plan pharmacy for up to a 30- day supply plus one 30- day refill for each prescription. For subsequent refills from a Plan pharmacy, or for all purchases from a Non- Plan pharmacy; only the deductible is waived; 40% coinsurance applies. If you have Medicare Parts A and B as your primary payer, copayments are waived for purchases made through the Mail Order Program; no deductible applies for mail order purchases.

1999 RI 71- 004 33

This Plan and Medicare continued

When Medicare is Primary

(continued)

When Medicare is the primary payer, this Plan will limit its payment to an amount that supplements the benefits that would be payable by Medicare, regardless of whether or not Medicare benefits are paid. However, the Plan will pay its 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 enrolled in Medicare, you may be asked by a physician to sign a private contract agreeing that you can billed directly for services that would ordinarily be covered by Medicare. Should you sign such an agreement, Medicare will not pay any portion of the charges, and you may receive less or no payment for those services under this Plan.

When you also enroll in a Medicare prepaid plan

When you are enrolled in a Medicare prepaid plan while you are a member of this Plan, you may continue to obtain benefits from this Plan. If you submit claims for services covered by this Plan that you receive from providers that are not in the Medicare plans network, the Plan will not waive any deductibles or coinsurance when paying these claims.

Medicare's payment and this Plan

If you are covered by Medicare Part B and it is primary, you should be aware that your out- of- pocket costs for services covered by both this Plan and Medicare Part B will depend on whether your doctor accepts Medicare assignment for the claim.

Doctors who participate with Medicare accept assignment; that is, they have agreed not to bill you for more than the Medicare- approved amount for covered services. Some doctors who do not participate with Medicare accept assignment on certain claims. If you use a doctor who accepts Medicare assignment for the claim, the doctor is permitted to bill you after the Plan has paid only when the Medicare and Plan payments combined do not total the Medicare- approved amount.

Doctors who do not participate with Medicare are not required to accept direct payment, or assignment, from Medicare. Although they can bill you for more than the amount Medicare would pay, Medicare law (the Social Security Act, 42 U. S. C.) sets a limit on how much you are obligated to pay. This amount, called the limiting charge, is 115 percent of the Medicare- approved amount. Under this law, if you use a doctor who does not accept assignment for the claim, the doctor is permitted to bill you after the Plan has paid only if the Medicare and Plan payments combined do not total the limiting charge. Neither you nor your FEHB Plan is liable for any amount in excess of the Medicare limiting charge for charges of a doctor who does not participate with Medicare. The Medicare Summary Notice (MSN) form will have more information about this limit.

If your doctor does not participate with Medicare, asks you to pay more than the limiting charge and he or she is under contract with this Plan, call the Plan. If your doctor is not a Plan doctor, ask the doctor to reduce the charge or report him or her to the Medicare carrier that sent you the Medicare MSN form. In any case, a doctor who does not participate with Medicare is not entitled to payment of more than 115 percent of the Medicare- approved amount.

How to claim benefits In most cases, when services are covered by both Medicare and this Plan, Medicare is the primary payer if you are an annuitant and this Plan is the primary payer if you are an employee. When

Medicare is the primary payer, your claims should first be submitted to Medicare. After Medicare has paid its benefits, the Carrier will consider the balance of any covered expenses. The Carrier has contracted with most Medicare Part B claims processors to receive electronic copies of your claims after Medicare has paid their benefits, thus eliminating the necessity for you to submit your Part B claims to this Plan. If you completed and returned to this Plan the Authorization Form sent you, you are included in this program. You may call the Carrier at 1- 800/ 222- APWU to obtain information about your status in this program, or to obtain an Authorization Form. If your claims are not being electronically filed, you must submit the MSN form from Medicare and duplicates of all bills along with a completed claim form. The Carrier will not process your claim without knowing whether you have Medicare and, if you do, without receiving the Medicare MSN.

Enrollment information If you are a new member Use this brochure as a guide to coverage and obtaining benefits. There may be a delay before you

receive your identification card and member information from the Carrier. Until you receive your ID card, you may show your copy of the SF 2809 enrollment form or your annuitant confirmation letter from OPM to a provider as proof of enrollment in this Plan. If you do not receive your ID card within 60 days after the effective date of your enrollment, you should contact the Carrier. See How

1999 RI 71- 004 34

Enrollment information continued

If you are a new member

(continued)

to claim benefits on page 26. If you made your open season change by using Employee Express and have not received your new ID card by the effective date of your enrollment, call the Employee Express HELP number to request a confirmation letter. Use that letter to confirm your new coverage with Plan providers.

If you are a new member of this Plan, benefits begin on the effective date of your enrollment, as set by your employing office or retirement system (see Effective date on page 37). Coverage under your new plan for a hospitalized member may be delayed if you are currently enrolled in another FEHB plan and you or a covered family member are hospitalized on the effective date of your enrollment; see If you are hospitalized below.

No FEHB plan may refuse to provide benefits for any condition you or a covered family member may have solely on the basis that it was a condition that existed before you enrolled in a plan under the FEHB Program.

If you are hospitalized If you change plans or options, benefits under your prior plan or option cease on the effective date of your enrollment in your new plan or option unless you or a covered family member are confined in a hospital or other covered facility or are receiving medical care in an alternative care setting on the last day of your enrollment under the prior plan or option. In that case, the confined person will continue to receive benefits under the former plan or option until the earliest of (1) the day the person is discharged from the hospital or other covered facility (a move to an alternative care setting does not constitute a discharge under this provision), or (2) the day after the day all inpatient benefits have been exhausted under the prior plan or option, or (3) the 92nd day after the last day of coverage under the prior plan or option. However, benefits for other family members under the new plan will begin on the effective date. If your plan terminates participation in the FEHB Program in whole or in part, or if the Associate Director for Retirement and Insurance orders an enrollment change, this continuation of coverage provision does not apply; in such case, the hospitalized family members benefits under the new plan begin on the effective date of enrollment.

Your responsibility It is your responsibility to be informed about your health benefits. Your employing office or retirement system can provide information about when you may change your enrollment; who "family members" are; what happens when you transfer, go on leave without pay, enter military service, or retire; when your enrollment terminates; and the next open season for enrollment. Your employing office or retirement system will also make available to you an FEHB Guide, brochures and other materials you need to make an informed decision.

Things to keep in mind

The benefits in this brochure are effective on January 1 for those already enrolled in this Plan. If you changed plans or plan options, see If you are a new member above. In both cases, however, the Plans new rates are effective the first day of the enrollee's first full pay period that begins on or after January 1 (January 1 for all annuitants).

Generally, you must be continuously enrolled in the FEHB Program for the last five years before you retire to continue your enrollment for you and any eligible family members after you retire.

The FEHB Program provides Self Only coverage for the enrollee alone or Self and Family coverage for the enrollee, his or her spouse, and unmarried dependent children under age 22. Under certain circumstances, coverage will also be provided under a family enrollment for a disabled child 22 years of age or older who is incapable of self- support.

An enrollee with Self Only coverage who is expecting a baby or the addition of a child may change to a Self and Family enrollment up to 60 days after the birth or addition. The effective date of the enrollment change is the first day of the pay period in which the child was born or became an eligible family member. The enrollee is responsible for his or her share of the Self and Family premium for that time period.

You will not be informed by your employing office (or your retirement system) or your Carrier when a family member loses eligibility. You must direct questions about enrollment and eligibility, including whether a dependent age 22 or older is eligible for coverage, to your employing office or retirement system. The Carrier does not determine eligibility and cannot change an enrollment status without the necessary information from the employing agency or retirement system.

1999 RI 71- 004 35

Enrollment information continued

Things to keep in mind

(continued)

An employee, annuitant, or family member enrolled in one FEHB plan is not entitled to receive benefits under any other FEHB plan.

Report additions and deletions (including divorces) of covered family members to the Carrier promptly.

If you are an annuitant or former spouse with FEHB coverage and you are also covered by Medicare Part B, you may drop your FEHB coverage and enroll in a Medicare prepaid plan when one is available in your area. If you later change your mind and want to reenroll in FEHB, you may do so at the next open season, or whenever you involuntarily lose coverage in the Medicare prepaid plan or move out of the area it serves. Most Federal annuitants have Medicare Part A. If you do not have Medicare Part A, you may enroll in a Medicare prepaid plan, but you will probably have to pay for hospital coverage in addition to the Part B premium. Before you join the plan, ask whether they will provide hospital benefits and, if so, what you will have to pay. You may also remain enrolled in this Plan when you join a Medicare prepaid plan. See page 33 for how this Plans benefits are affected when you are enrolled in a Medicare prepaid plan. Contact your local Social Security Administration (SSA) office for information on local Medicare plans (also known as Coordinated Care Plans or Medicare HMOs) or request it from SSA at 1- 800/ 638- 6833. Contact your retirement system for information on dropping your FEHB enrollment and changing to a Medicare prepaid plan.

Federal annuitants are not required to enroll in Medicare Part B (or Part A) in order to be covered under the FEHB Program nor are their FEHB benefits reduced if they do not have Medicare Part B (or Part A).

Coverage after enrollment ends

When an employee's enrollment terminates because of separation from Federal service or when a family member is no longer eligible for coverage under an employee or annuitant enrollment, and the person is not otherwise eligible for FEHB coverage, he or she will generally be eligible for a free 31- day extension of coverage. The employee or family member may also be eligible for one of the following:

Former spouse coverage When a Federal employee o