1999 FEHB brochure-file c.qrk4

BlueLincs HMO 1999 A Health Maintenance Organization

BlueLincs HMO has received One- Year Accreditation from the National Committee for QualityAssurance (NCQA). See the 1999 Guide for more information on NCQA.

Serving: Oklahoma City, Tulsa, Lawton, SW Oklahoma areas. Enrollment in this Plan is limited; see page (9) for requirements.

Enrollment code: N51 Self only N52 Self and family

Visit the OPM Website at http:// www. opm. gov/ insure and this Plans Website at http:// www. bcbsok. com. Authorized for distribution by the:

For changes and benefits see page 22.

RI 73- 267

BlueLincs HMO

BlueLincs HMO, 1400 South Boston, Tulsa, Oklahoma 74119, has entered into a contract (CS 2074) with the Office of Personnel Management (OPM) as authorized by the Federal Employees Health Benefits (FEHB) law, to provide a comprehensive medical plan herein called BlueLincs or the Plan.

This brochure is the official statement of benefits on which you can rely. A person enrolled in the Plan is entitled to the benefits stated in this brochure. If enrolled for Self and Family, each eligible family member is also entitled to these benefits.

Premiums are negotiated with each plan annually. Benefit changes are effective January 1, 1999, and are shown on page (22) of this brochure.

Table of Contents Page Inspector General Advisory on Fraud . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2- 5

Confidentiality; If you are a new member; If you are hospitalized when you change plans; Your responsibility; Things to keep in mind; Coverage after enrollment ends (Former spouse coverage; Temporary continuation of coverage; Notification and election requirements; Conversion to individual coverage; and Certificate of Creditable Coverage)

Facts about BlueLincs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6- 9

Information you have the right to know; Who provides care to Plan members? Role of a primary care doctor; Choosing your doctor; Referrals for specialty care; Authorizations; For new members; Hospital care; Out- of- pocket maximum; Deductible carryover; Submit claims promptly; Experimental/ investigative determinations; Other considerations; Reciprocity; The Plans service area.

General Limitations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 10- 11

Important notice; Circumstances beyond Plan control; Other sources of benefits

General Exclusions. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11 Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12- 18

Medical and Surgical Benefits; Hospital/ Extended Care Benefits; Emergency Benefits, Mental Conditions/ Substance Abuse Benefits; Prescription Drug Benefits

Other Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 18

Dental care

Non- FEHB Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19 How to Obtain Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20- 21 Program- wide Changes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 How BlueLincs Changes January 1999 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22 Summary of Benefits . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

RI 73- 267 1

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. This could 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 or pharmacy, 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 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 plan at 1- 800- 722- 5675 and explain the

situation. If the matter is not resolved after speaking to your plan (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 services 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.

General Information Confidentiality

Medical and other information provided to the Plan, including claim files, is kept confidential and will be used only: 1) by the Plan 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.

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 Plan. 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 or Plan facility 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 Plan.

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 and rates begin on the effective date of your enrollment, as set by your employing office or retirement system. As a member of this Plan, once your enrollment is effective, you will be covered only for services provided or arranged by a Plan doctor except in the case of emergency as described on page 16. If you are confined in a hospital on the effective date, you must notify the Plan so that it may arrange for the transfer of your care to Plan providers. See If you are hospitalized on page 3.

FEHB plans may not 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.

General Information continued 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 on page 2. In both cases, however, the Plans new rates are effective the first day of the enrollees 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; both parent and child are covered only for care received from Plan providers, except for emergency benefits.

You will not be informed by your employing office (or your retirement system) or your Plan 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 Plan does not determine eligibility and cannot change an enrollment status without the necessary information from the employing agency or retirement system.

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 Plan 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.

General Information continued

You may also remain enrolled in this Plan when you join a Medicare prepaid plan. Contact your local Social Security Administration (SSA) office for information on local Medicare prepaid 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 employees 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 generally will 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 or annuitant divorces, the former spouse may be eligible to elect coverage under the spouse equity law. If you are recently divorced or anticipate divorcing, contact the employees employing office (personnel office) or retirees retirement system to get more facts about electing coverage.

Temporary continuation of coverage (TCC)

If you are an employee whose enrollment is terminated because you separate from service, you may be eligible to temporarily continue your health benefits coverage under the FEHB Program in any plan for which you are eligible. Ask your employing office for RI 79- 27, which describes TCC, and for RI 70- 5, the FEHB Guide for individuals eligible for TCC. Unless you are separated for gross misconduct, TCC is available to you if you are not otherwise eligible for continued coverage under the Program. For example, you are eligible for TCC when you retire if you are unable to meet the five- year enrollment requirement for continuation of enrollment after retirement.

Your TCC begins after the initial free 31- day extension of coverage ends and continues for up to 18 months after your separation from service (that is, if you use TCC until it expires 18 months following separation, you will only pay for 17 months of coverage). Generally, you must pay the total premium (both the Government and employee shares) plus a 2 percent administrative charge. If you use your TCC until it expires, you are entitled to another free 31- day extension of coverage when you may convert to nongroup coverage. If you cancel your TCC or stop paying premiums, the free 31- day extension of coverage and conversion option are not available.

Children or former spouses who lose eligibility for coverage because they no longer qualify as family members (and who are not eligible for benefits under the FEHB Program as employees or under the spouse equity law) also may qualify for TCC. They also must pay the total premium plus the 2 percent administrative charge. TCC for former family members continues for up to 36 months after the qualifying event occurs, for example, the child reaches age 22 or the date of the divorce. This includes the free 31- day extension of coverage. When their TCC ends (except by cancellation or nonpayment of premium), they are entitled to another free 31- day extension of coverage when they may convert to nongroup coverage.

NOTE: If there is a delay in processing the TCC enrollment, the effective date of the enrollment is still the 32nd day after regular coverage ends. The TCC enrollee is responsible for premium payments retroactive to the effective date and coverage may not exceed the 18 or 36 month period noted above.

Notification and election requirements Separating employees Within 61 days after an employees enrollment terminates because of separation from service, his or her employing office must notify the employee of the opportunity to elect TCC. The employee has 60 days after separation (or after receiving the notice from the employing office, if later) to elect TCC.

Children You must notify your employing office or retirement system when a child becomes eligible for TCC within 60 days after the qualifying event occurs, for example, the child reaches age 22 or marries.

General Information continued Former spouses You or your former spouse must notify the employing office or retirement system of the former spouses eligibility for TCC within 60 days after the termination of the marriage. A former spouse may also qualify for TCC if, during the 36- month period of TCC eligibility, he or she loses spouse equity eligibility because of remarriage before age 55 or loss of the qualifying court order. This applies even if he or she did not elect TCC while waiting for spouse equity coverage to begin. The former spouse must contact the employing office within 60 days of losing spouse equity eligibility to apply for the remaining months of TCC to which he or she is entitled.

The employing office or retirement system has 14 days after receiving notice from you or the former spouse to notify the child or the former spouse of his or her rights under TCC. If a child wants TCC, he or she must elect it within 60 days after the date of the qualifying event (or after receiving the notice, if later). If a former spouse wants TCC, he or she must elect it within 60 days after any of the following events: the date of the qualifying event or the date he or she receives the notice, whichever is later; or the date he or she loses coverage under the spouse equity law because of remarriage before age 55 or loss of the qualifying court order.

Important: The employing office or retirement system must be notified of a childs or former spouses eligibility for TCC within the 60- day time limit. If the employing office or retirement system is not notified, the opportunity to elect TCC ends 60 days after the qualifying event in the case of a child and 60 days after the change in status in the case of a former spouse.

Conversion to individual coverage

When none of the above choices are available or chosen when coverage as an employee or family member ends, or when TCC coverage ends (except by cancellation or nonpayment of premium), you may be eligible to convert to an individual, nongroup contract. You will not be required to provide evidence of good health and the plan is not permitted to impose a waiting period or limit coverage for preexisting conditions. If you wish to convert to an individual contract, you must apply in writing to the carrier of the plan in which you are enrolled within 31 days after receiving notice of the conversion right from your employing agency. A family member must apply to convert within the 31- day free extension of coverage that follows the event that terminates coverage, e. g., divorce or reaching age 22. Benefits and rates under the individual contract may differ from those under the FEHB Program.

Certificate of Creditable Coverage

Under Federal law, if you lose coverage under the FEHB Program, you should automatically receive a Certificate of Group Health Plan Coverage from the last FEHB Plan to cover you. This certificate, along with any certificates you receive from other FEHB plans you may have been enrolled in, may reduce or eliminate the length of time a preexisting condition clause can be applied to you by a new non- FEHB insurer. If you do not receive a certificate automatically, you must be given one on request.

Facts about BlueLincs

This Plan is a comprehensive medical plan, sometimes called a health maintenance organization (HMO). When you enroll in an HMO, you are joining an organized system of health care that arranges in advance with specific doctors, hospitals and other providers to give care to members and pays them directly for their services. Benefits are available only from Plan providers except during a medical emergency. Members are required to select a personal doctor from among participating Plan primary care doctors. Services of a specialty care doctor can only be received by referral from the selected primary care doctor. There are no claim forms when Plan doctors are used.

Your decision to join an HMO should be based on your preference for the plans benefits and delivery system, not because a particular provider is in the plans network. You cannot change plans because a provider leaves the HMO.

Because the Plan provides your care and pays the cost, it seeks efficient and effective delivery of health services. By controlling unnecessary or inappropriate care, it can afford to offer a comprehensive range of benefits. In addition to providing comprehensive health services and benefits for accidents, illness and injury, the Plan places great emphasis on preventive benefits such as office visits, physicals, immunizations and well- baby care. You are encouraged to get medical attention at the first sign of illness.

Information you have All carriers in the FEHB Program must provide certain information to you. If you

the right to know did not receive information about this Plan, you can obtain it by calling the Carrier at (800/ 722- 5675) or you may write the Carrier at (P. O. Box 3283, Tulsa, OK 74112- 3283). You may also contact the Carrier by fax at 918/ 561- 9980, at its webside at http:// www. bcbsok. com or by email at bcbsok@ bcbsok. com.

Information that must be made available to you includes: Disenrollment rate for 1997. Compliance with State and Federal licensing or certification and the dates met. If noncompliant, the reason for noncompliance. Accreditations by recognized accrediting agencies and the dates received. Carriers type of corporate form and years in existence. Whether the Carrier meets State, Federal and accreditation requirements for fiscal solvency, confidentiality and transfer of medical records.

Who provides care BlueLincs HMO is an Individual Practice Association Health Maintenance

to Plan members? Organization. BlueLincs HMO offers each individual a choice of over 500 personal primary care doctors (M. D. s and D. O. s) so that each family member can receive care that is best suited to them. In addition, the BlueLincs HMO provider network includes 36 major hospitals for inpatient care, more than 400 pharmacy locations and over 1100 specialist doctors for referral care.

Role of a primary The first and most important decision each member must make is the selection of a

care doctor primary care doctor. The decision is important since it is through this doctor that all other health services, particularly those of specialists, are obtained. It is the responsibility of your primary care doctor to obtain any necessary authorizations from the Plan before referring you to a specialist or making arrangements for hospitalization. Services of other providers are covered only when you have been referred by your primary care doctor. A woman may see her Plan obstetrician/ gynecologist for her annual examination without a referral. Simply call a Member Services representative (1- 800/ 722- 5675) and tell him/ her that you are self- referring to a participating BlueLincs gynecologist. A man may self refer to a Plan urologist once a year for a routine exam.

Choosing your The Plans provider directory lists primary care doctors (generally family practitioners,

doctor pediatricians, and internists) with their locations and phone numbers and notes whether or not the doctor is accepting new patients. Directories are updated on a regular basis and are available at the time of enrollment. They can be viewed on Blue Cross and Blue Shield of Oklahomas internet web site on the world wide web at www. bcbsok. com, or can be requested by calling the Member Services Department at 1- 800/ 722- 5675; you can also find out if your doctor participates with this Plan by calling this 1- 800 number.

Facts about BlueLincs continued

If you are interested in receiving care from a specific provider who is listed in the directory, call the provider to verify that he or she still participates with the Plan and is accepting new patients. Important note: When you enroll in this Plan, services (except for emergency benefits) are provided through the Plans delivery system; the continued availability and/ or participation of any one doctor, hospital, or other provider cannot be guaranteed.

If you enroll, you will be asked to let the Plan know which primary care doctor( s) youve selected for you and each member of your family by sending a selection form to the Plan. If you need help choosing a doctor, call the Plan. Members may change their doctor selection by notifying the Plan 30 days in advance.

In the event a member is receiving services from a doctor who terminates a participation agreement, the Plan will provide payment for covered services until the Plan can make reasonable and medically appropriate provisions for the assumption of such services by a participating doctor.

Referrals for Except in a medical emergency or when a primary care doctor has designated another doctor

specialty care to see patients when he or she is unavailable, you must contact your primary care doctor for a referral before seeing any other doctor or obtaining special services. Referral to a participating specialist is given at the primary care doctors discretion; if specialists or consultants are required beyond those participating in the Plan, the primary care doctor will make arrangements for appropriate referrals.

When you receive a referral from your primary care doctor, you must return to the primary care doctor after the consultation unless your doctor authorizes additional visits. All follow- up care must be provided or authorized by the primary care doctor. Do not go to the specialist for a second visit unless your primary care doctor has arranged for, and the Plan has issued an authorization for the referral in advance. A female may self- refer to a participating Bluelincs obstetrician/ gynecologist once a year for her annual examination. The annual examination includes pelvic exam, pap smear, and breast exam for the office visit copayment. A referral from your primary care physician is not needed for this benefit. Any follow- up visits from this provider MUST BE AUTHORIZED from your primary care physician. All maternity care will continue to be coordinated by your primary care physician. A male may self- refer to a participating BlueLincs urologist once a year for his annual examination. The annual examination includes the office visit and prostate examination, but it does not include the Prostate Specific Antigen test, PSA. A referral from your primary care physician is not necessary. Simply contact a Member Services representative to advise that you are self- referring. If you are receiving services from a doctor who leaves the Plan, the Plan will pay for covered services until the Plan can arrange with you to be seen by another participating doctor.

If you have a chronic, complex or serious medical condition that causes you to see a Plan specialist frequently, your primary care doctor will develop a treatment plan with you and your health plan that allows an adequate number of direct access visits with that specialist. The treatment plan will permit you to visit your specialist without the need to obtain further referrals.

Authorizations The Plan will provide benefits for covered services only when the services are medically necessary to prevent, diagnose or treat your illness or condition. Your plan doctor must obtain the Plans determination of medical necessity before you may be hospitalized, referred for specialty care or obtain follow- up care from a specialist.

For new members If you are already under the care of a specialist who is a Plan participant, you must still obtain a referral from a Plan primary care doctor for the care to be covered by the Plan. If the doctor who originally referred you prior to your joining this Plan is now your Plan primary care doctor, you need only call to explain that you are now a Plan member and ask that you be referred for your next appointment.

If you are selecting a new primary care doctor and want to continue with this specialist, you must schedule an appointment so that the primary care doctor can decide whether to treat the condition directly or refer you back to the specialist.

Facts about BlueLincs continued Hospital care If you require hospitalization, your primary care doctor or authorized specialist will make

the necessary arrangements and continue to supervise your care.

Out- of- pocket Copayments are required for a few benefits. However, copayments will not be required for

maximum the remainder of the calendar year after your out- of- pocket expenses for services provided or arranged by the Plan reach $1,000 per Self Only enrollment or $3,000 per Self and Family enrollment. This copayment maximum does not include costs of prescription drugs.

You should maintain accurate records of the copayments made, as it is your responsibility to determine when the copayment maximum is reached. You are assured a predictable maximum in out- of- pocket costs for covered health and medical needs. Copayments are due when service is rendered, except for emergency care.

Deductible If you changed to this Plan during open season from a plan with a deductible and the

carryover effective date of the change was after January 1, any expenses that would have applied to that plans deductible 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 January 1.

Submit claims When you are required to submit a claim to this Plan for covered expenses, submit your

promptly claim promptly. The Plan will not pay benefits for claims submitted later than December 31 of the calendar year following the year in which the expense was incurred, unless timely filing was prevented by administrative operations of Government or legal incapacity, provided the claim was submitted as soon as reasonably possible.

Experimental/ The Plan uses a multi- step process employing health care data analysis, scientific literature

investigative review, and clinical consensus to provide the highest level of confidence in its criteria

determinations and protocols.

Other Plan providers will follow generally accepted medical practice in prescribing any course

considerations of treatment. Before you enroll in this Plan, you should determine whether you will be able to accept treatment or procedures that may be recommended by Plan providers.

Reciprocity The Plan provides non- emergency and specialty care outside of the service area. Services are provided through a reciprocal agreement with HMO- USA, a national network of Blue Cross and Blue Shield health maintenance organizations. The member is required to arrange the reciprocal coverage with BlueLincs doctors prior to obtaining services.

Facts about BlueLincs continued The Plans service area

The service area for this Plan, where Plan providers and facilities are located, is described below. You must live or work in the service area to enroll in the Plan. You may enroll in this Plan if you live or work inside the service area or live in the geographic area described below. Benefits for care outside the service area are limited to emergency services, as described on page 16.

If you or a covered family member move outside the enrollment area or no longer work there, you may enroll in another approved plan. It is not necessary to wait until you move or for the open season to make such a change; contact your employing office or retirement system for information if you are anticipating a move.

Service Area: Services from Plan providers are available only in the area described. The following counties are eligible Service Areas in their entirety:

Adair Grady Mayes Payne Canadian Greer McClain Pottawatomie Cherokee Harmon McIntosh Rogers Cleveland Jackson Muskogee Stephens Comanche Kiowa Okfuskee Tillman Cotton Lincoln Oklahoma Tulsa Creek Logan Okmulgee Wagoner

The following zip codes are also eligible Service Areas:

Enrollment area: You must live or work in the Service Area to enroll in this Plan. 9 73001 Albert

73520 Addington 73005 Anadarko 73035 Antioch 73006 Apache 74633 Apperson 74001 Avant 74002 Barnsdall 74332 Big Cabin 73009 Binger 74830 Bowlegs 74962 Box 73625 Butler 74425 Canadian 73626 Canute 73015 Carnegie 73627 Carter 73016 Cashion 73017 Cement 73628 Cheyenne 74020 Cleveland 74837 Cromwell

73059 Cogar 73029 Cyril 73641 Dill City 74839 Dustin 73644 Elk City 73648 Elk City 73038 Fort Cobb 73647 Foss 73039 Foster 73040 Geary 74435 Gore 73042 Gracemont 73437 Graham 73043 Greenfield 74034 Hallett 73650 Hammon 73548 Hastings 73046 Hennepin 73047 Hinton 74035 Hominy 74440 Hoyt 74442 Indianola

74038 Jennings 73750 Kingfisher 74552 Kinta 74849 Konawa 74850 Lamar 73052 Lindsay 73053 Lookeba 73756 Loyal 73757 Lucien 73057 Maysville 74048 Nowata 74359 Oaks 74051 Ochelata 73762 Okarche 73764 Omega 74054 Osage 73074 Paoli 73075 Pauls Valley 73076 Pernell 73077 Perry 74060 Prue 74561 Quinton

74061 Ramona 73081 Ratliff City 73661 Rocky 73662 Sayre 74868 Seminole 73664 Sentinel 74070 Skiatook 74462 Stigler 74081 Terlton 73088 Tussy 74368 Twin Oaks 74082 Vera 74962 Vian 74301 Vinita 73094 Washita 73772 Watonga 73573 Waurika 74883 Wetumka 74884 Wewoka 74472 Whitefield 74854 Wolf 73098 Wynnewood

General Limitations Important notice Although a specific service may be listed as a benefit, it will be covered for you only if, in

the judgment of your Plan doctor, it is medically necessary for the prevention, diagnosis, or treatment of your illness or condition. 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 this Plan or be used in the prosecution or defense of a claim under this Plan. This brochure is the official statement of benefits on which you can rely.

Circumstances In the event of major disaster, epidemic, war, riot, civil insurrection, disability of a

beyond Plan significant number of Plan providers, complete or partial destruction of facilities, or other

control circumstances beyond the Plans control, the Plan will make a good faith effort to provide or arrange for covered services. However, the Plan will not be responsible for any delay or failure in providing service due to lack of available facilities or personnel.

Other sources This section applies when you or your family members are entitled to benefits from a

of benefits source other than this Plan. You must disclose information about other sources of benefits to the Plan and complete all necessary documents and authorizations requested by the Plan.

Medicare If you or a covered family member is enrolled in this Plan and Medicare part A and/ or Part B, the Plan will coordinate benefits according to Medicares determination of which coverage is primary. However, this Plan will not cover services, except those for emergencies, unless you use Plan providers (or the services are covered under this Plans POS benefits). You must tell your Plan that you or your family member is eligible for Medicare. Generally, that is all you will need to do, unless your Plan tells you that you need to file a Medicare claim.

Group health This coordination of benefits (double coverage) provision applies when a person covered by

insurance and this Plan also has, or is entitled to benefits from, any other group health coverage or is

automobile entitled to the payment of medical and hospital costs under no- fault or other automobile

insurance insurance that pays benefits with regard to fault. Information about the other coverage must be disclosed to this Plan.

When there is double coverage for covered benefits, other than emergency services from non- Plan providers, this Plan will continue to provide its benefits in full, but is entitled to receive payment for the services and supplies provided, to the extent that they are covered by the other coverage, no- fault or other automobile insurance or any other primary plan.

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 (l) its benefits in full, or is entitled to (2) a reduced amount which, when added to the benefits payable by the other coverage, will not exceed reasonable charges. 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. 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 Plan 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. As a member of a prepaid plan, special limitations on your CHAMPUS coverage apply; your primary provider must authorize all care. See your CHAMPUS Health Benefits Advisor if you have questions about CHAMPUS coverage.

Medicaid If you are covered by both this Plan and Medicaid, this Plan will pay benefits first. 10

General Limitations continued Workers The Plan will not pay for services required as the result of occupational disease or

compensation 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, this Plan will be financially responsible for services or supplies that are otherwise covered by this Plan. The Plan is entitled to be reimbursed by OWCP (or the similar agency) for services it provided that were later found to be payable by OWCP (or the agency).

DVA facilities, Facilities of the Department of Veterans affairs, the Department of Defense, and the

DOD facilities, Indian Health Service are entitled to seek reimbursement from the Plan for certain

and Indian services and supplies provided to you or a family member to the extent that

Health Service reimbursement is required under the Federal statutes governing such facilities.

Other Government The Plan will not provide benefits for services and supplies paid for directly or

agencies indirectly by any other local, State, or Federal Government agency.

Liability insurance If a covered person is sick or injured as a result of the act or omission of another

and third party person or party, the Plan requires that it be reimbursed for the benefits provided in

actions an amount not to exceed the amount of the recovery, or that it be subrogated to the persons rights to the extent of the benefits received under this Plan, including the right to bring suit in the persons name. If you need more information about subrogation, the Plan will provide you with its subrogation procedures.

General Exclusions

All benefits are subject to the limitations and exclusions in this brochure. Although a specific service may be listed as a benefit, it will not be covered for you unless your Plan doctor determines it is medically necessary to prevent, diagnose or treat your illness or condition as discussed under Authorizations on page 7. The following are excluded:

Care by non- Plan doctors or hospitals except for authorized referrals or emergencies (see Emergency Benefits)

Expenses incurred while not covered by this Plan; Services furnished or billed by a provider or facility barred from the FEHB Program; Services not required according to accepted standards of medical, dental, or psychiatric practice;

Procedures, treatments, drugs or devices that are experimental or investigational; Procedures, services, drugs, and supplies related to sex transformations; and 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 an act of rape or incest.

Medical and Surgical Benefits What is covered A comprehensive range of preventive, diagnostic and treatment services is provided by Plan

doctors and other Plan providers. This includes all necessary office visits; you pay a $5 office visit copay, but no additional copay for laboratory tests and X- rays. Within the Service Area, house calls will be provided if in the judgment of the Plan doctor such care is necessary and appropriate; you pay a $5 copay for a doctors house call, and nothing for home visits by nurses and health aides.

You pay a $5 copay for each inpatient physician visit and any charges noted below: The following services are included: Preventive care, including well baby care and periodic check- ups Mammograms are covered as follows: for women age 35 through 39, one mammogram during these 5 years; for women age 40 through 49, one mammogram every one or two years; for women age 50 through 64, one mammogram every two years. In addition to routine screenings, mammograms are covered when prescribed by the doctor as medically necessary to diagnose or treat your illness.

Routine immunizations and boosters Consultations by specialists Diagnostic procedures, such as laboratory tests and X- rays Complete obstetrical (maternity) care for all covered females, including prenatal, delivery and postnatal care by a Plan doctor (office visit copays are waived for obstetrical care). 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. If enrollment in the Plan is terminated during pregnancy, benefits will not be provided after coverage under the Plan has ended. Ordinary nursery care of the newborn child during the covered portion of the mothers hospital confinement for maternity will be covered under either a Self Only or Self and Family enrollment; other care of an infant who requires definitive treatment will be covered only if the infant is covered under a Self and Family enrollment.

Voluntary sterilization, insertion of IUDs and family planning services Diagnosis and treatment of diseases of the eye Vision and hearing screening up to age 19 (one per year), with referral to a specialist when appropriate

Allergy testing and treatment (copay is not required if physician is not seen) Biological serum, you pay 50% of covered charges The insertion of internal prosthetic devices, such as pacemakers and artificial joints. Cornea, heart, heart- lung, kidney, liver, lung (single or double), pancreas- kidney, and skin transplants. Allogeneic (donor) bone marrow transplants; autologous bone marrow transplants (autologous stem cell and peripheral stem cell support) for the following conditions: acute lymphocytic or non- lymphocytic leukemia, advanced Hodgkins lymphoma, advanced non- Hodgkins lymphoma, advanced neuroblastoma, breast cancer, multiple myeloma, epithelial ovarian cancer, and testicular, mediastinal, retroperitoneal and ovarian germ cell tumors. Transplants are covered when approved by the Medical Director. Related medical and hospital expenses of the donor are covered when the recipient is covered by this Plan.

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.

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Medical and Surgical Benefits continued What is covered (cont.) Dialysis

Surgical treatment of morbid obesity Chemotherapy, radiation therapy; and inhalation therapy Home health services of nurses and health aides, including intravenous fluids and medications when prescribed by your Plan doctor, who will periodically review the program for continuing appropriateness and need

Chiropractic services

Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects, such as cleft lip and cleft palate, and for medical or surgical procedures occurring within or adjacent to the oral cavity or sinuses including, but not limited to, treatment of fractures and excision of tumors and cysts. All other procedures involving the teeth or intra- oral areas surrounding the teeth are not covered, including shortening of the mandible or maxillae for cosmetic purposes, correction of malocclusion, and any dental care involved in treatment of temporo- mandibular joint (TMJ) pain dysfunction syndrome.

Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from an injury or surgery that has produced a major effect on the members appearance and if the condition can reasonably be expected to be corrected by such surgery.

Short- term rehabilitative therapy (physical, speech and occupational) is provided on an inpatient or outpatient basis for up to three consecutive months per condition if significant improvement can be expected within three months; you pay a $10 copay per visit. Speech therapy is limited to treatment of certain speech impairments of organic origin. Occupational therapy is limited to services that assist the member to achieve and maintain self- care and improved functioning in other activities of daily living.

Durable medical equipment, such as wheelchairs, and hospital beds, prosthetics, such as lenses following cataract removal, and orthopedic devices such as foot orthotics. You pay 20% of all covered charges up to a maximum benefit of $l, 000 per member per calendar year.

Diagnosis and treatment of infertility is covered; you pay 50% of all charges. The following type( s) of artificial insemination are covered: ICI, IUI and IVI; you pay 50% of all charges; cost of donor sperm is not covered. Other assisted reproductive technology (ART) procedures, such as in vitro fertilization and embryo transfer, are not covered. Fertility drugs are not covered.

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Medical and Surgical Benefits continued What is not Physical examinations that are not necessary for medical reasons, such as those

covered required for obtaining or continuing employment or insurance, attending school or camp, or travel

Reversal of voluntary, surgically- induced sterility Surgery primarily for cosmetic purposes Hearing aids Homemaker services Refractions, including lens prescriptions Long- term rehabilitative therapy Corrective eyeglasses and frames or contact lenses (including the fitting of the lenses) Transplants not listed as covered Blood and blood derivatives not replaced by the member Cardiac rehabilitation

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Hospital/ Extended Care Benefits What is covered

Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan doctor. You pay nothing. You pay a $5 copay for each inpatient physician visit. All necessary services are covered, including:

Semi- private room accommodations; when a Plan doctor determines it is medically necessary, the doctor may prescribe private accommodations or private duty nursing care

Specialized care units, such as intensive care or cardiac care units

Extended care The Plan provides a comprehensive range of benefits with no dollar or day limit when full- time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a Plan doctor and approved by the Plan. You pay

nothing. All necessary services are covered, including: Bed, board and general nursing care Drugs, biologicals, supplies, and equipment ordinarily provided or arranged by the skilled nursing facility when prescribed by a Plan doctor

Hospice care Supportive and palliative care for a terminally ill member is covered in the home or a hospice facility. Services include inpatient and outpatient, and family counseling; these services are provided under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness, with a life expectancy of approximately six months or less.

Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor.

Limited benefits Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor

procedures determines there is a need for hospitalization for reasons totally unrelated to the dental procedure; the Plan will cover the hospitalization, but not the cost of the professional dental services. Conditions for which hospitalization would be covered include hemophilia and heart disease; the need for anesthesia, by itself, is not such a condition.

Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency

detoxification care, diagnosis, treatment of medical conditions, and medical management of withdrawal symptoms (acute detoxification) if the Plan doctor determines that outpatient management is not medically appropriate. See page 17 for nonmedical substance abuse benefits.

What is not Personal comfort items, such as telephone and television

covered

Blood and blood derivatives not replaced by the member Custodial care, rest cures, domiciliary or convalescent care

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Emergency Benefits What is a A medical emergency is the sudden and unexpected onset of a condition or an injury you

medical believe endangers your life or could result in serious injury or disability, and requires

emergency? immediate medical or surgical care. Some problems are emergencies because, if not treated promptly, they might become more serious; examples include deep cuts and broken bones. Others are emergencies because they are potentially life- threatening, such as heart attacks, strokes, poisonings, gunshot wounds or sudden inability to breathe. There are many other acute conditions that the Plan may determine are medical emergencies what they all have in common is the need for quick action.

Emergencies within If you are in an emergency situation, please call your primary care doctor. In extreme

the servicearea emergencies, if you are unable to contact your doctor, contact the local emergency system (e. g., the 911 telephone system) or go to the nearest hospital emergency room. Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan. You or a family member must notify the Plan within 48 hours. It is your responsibility to ensure that the Plan has been timely notified.

If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If you are hospitalized in non- Plan facilities and Plan doctors believe care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

Benefits are available for care from non- Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death, disability or significant jeopardy to your condition.

To be covered by this Plan, any follow- up care recommended by non- Plan providers must be approved by the Plan or provided by Plan providers.

Plan pays... Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers.

You pay... $50 per hospital emergency room visit and $25 per visit to a participating minor emergency or urgent care center for emergency services that are covered benefits of this Plan. If the emergency results in admission to a hospital, the emergency care copay is waived.

Emergencies outside Benefits are available for any medically necessary health service that is immediately

the servicearea required because of injury or unforeseen illness. If you need to be hospitalized, the Plan must be notified within 48 hours or on the first working day following your admission, unless it was not reasonably possible to notify the Plan within that time. If a Plan doctor believes care can be better provided in a Plan hospital, you will be transferred when medically feasible with any ambulance charges covered in full.

Plan pays... Reasonable charges for emergency care services to the extent the services would have been covered if received from Plan providers.

You pay... $50 per hospital emergency room visit for emergency services that are covered benefits of this Plan. If the emergency results in admission to a hospital, the emergency care copay is waived.

What is covered Emergency care at a doctors office or an urgent care center Emergency care as an outpatient or inpatient at a hospital, including doctors services Ambulance service approved by the Plan

What is not Elective care or non- emergency care

covered Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area Medical and hospital costs resulting from a normal full- term delivery of a baby outside the service area

Emergency Benefits continued Filing claims With your authorization, the Plan will pay benefits directly to the providers of your

emergency care upon receipt of their claims. Physician claims should be submitted on the HCFA 1500 claim form. If you are required to pay for the services, submit itemized bills and your receipts to the Plan along with an explanation of the services and the identification information from your ID card.

Payment will be sent to you (or the provider if you did not pay the bill), unless the claim is denied. If it is denied, you will receive notice of the decision, including the reasons for the denial and the provisions of the contract on which denial was based. If you disagree with the Plans decision, you may request reconsideration in accordance with the disputed claims procedure described on page 20.

Mental Conditions/ Substance Abuse Benefits Mental conditions

What is covered To the extent shown below, the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions, including the treatment of mental illness or disorders: Diagnostic evaluation Psychological testing Psychiatric treatment (including individual and group therapy) Hospitalization (including inpatient professional services)

Outpatient Up to 40 outpatient visits to Plan doctors, consultants or other psychiatric personnel

care each calendar year; you pay a $20 copay for each covered visit all charges thereafter.

Inpatient Up to 30 days of hospitalization each calendar year; you pay nothing for first 30

care days all charges thereafter.

What is not Care for psychiatric conditions that in the professional judgment of Plan doctors

covered are not subject to significant improvement through relatively short- term treatment Psychiatric evaluation or therapy on court order or as a condition of parole or probation, unless determined by a Plan doctor to be necessary and appropriate Psychological testing that is not medically necessary to determine the appropriate treatment of a short- term psychiatric condition

The medical management of mental conditions will be covered under this Plans Medical and Surgical Benefits provisions. Related drug costs will be covered under this Plans Prescription Drug Benefits, and any costs for psychological testing or psychotherapy will be covered under this Plans Mental Conditions Benefits.

Substance abuse What is covered This Plan provides medical and hospital services such as acute detoxification services for

the medical non- psychiatric aspects of substance abuse, including alcoholism and drug addiction, the same as for any other illness or condition. Services for the psychiatric aspects are provided in conjunction with the mental conditions benefit shown above. Outpatient visits to Plan mental conditions providers for follow- up care and counseling are covered, as well as inpatient services necessary for diagnosis and treatment. The mental conditions visit/ day limitations and copays apply.

What is not Treatment which is not authorized by a Plan doctor

covered CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Prescription Drug Benefits What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy

will be dispensed for up to a 30- day supply; you pay a $5 copay per prescription unit or refill for generic drugs, and a $10 copay per prescription unit or refill for name brand drugs. Nonformulary drugs will be covered when prescribed by a Plan doctor.

Formulary The Plans formulary consists of a list of commonly prescribed medications that have been chosen by the Plan based on a drugs effectiveness and cost. The Plan will evaluate any needed additions to or deletions from the formulary. Nonformulary drugs will be covered when prescribed by a Plan doctor.

Covered medications and accessories include: Drugs for which a prescription is required by law; Oral contraceptive drugs; Insulin; Disposable needles and syringes needed for injecting covered prescribed

medications; Intravenous fluids and medication for home use, implantable drugs, and some injectable drugs are covered under Medical and Surgical Benefits; Diabetic supplies including glucose test tablets and test tape; Benedicts solution or equivalent and acetone test tablets.

What is not Drugs available without a prescription or for which there is a non- prescription

covered equivalent available Drugs obtained at a non- Plan pharmacy except for out- of- area emergencies Vitamins and nutritional substances that can be purchased without a prescription Medical supplies such as dressings and antiseptics Contraceptive devices including Norplant; injectable contraceptives Drugs for cosmetic purposes Drugs to enhance athletic performance Smoking cessation drugs and medication, including nicotine patches Fertility drugs

Other Benefits Dental care

Accidental injury Restorative services and supplies necessary to promptly repair and replace

sound Benefit natural teeth. The need for these services must result from an accidental injury that occurred while in a plan under the FEHB Program; you pay nothing.

What is not Other dental services not shown as covered

covered CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Non- FEHB Benefits Available to Plan Members

The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program, but are made available to all enrollees and family members who are members of this Plan. The cost of the benefits described on this page is not included in the FEHB premium; any charges for these services do not count toward any FEHB deductibles, outof- pocket maximum copay charges, etc. These benefits are not subject to the FEHB disputed claims procedures.

BlueLincs Dental

ATTENTION! BlueLincs enrollees are eligible to join BlueLincs Dental. BlueLincs Dental benefit highlights include:

Simple and Convenient No Deductibles No Waiting Period Before Benefits Begin No Claims to File

100% Coverage for Diagnostic and Preventative Services Six- month Exams Cleanings X- Rays

Full Range of Benefits Diagnostic Preventative Restorative Endodontics Orthodontics For Children and Adults ($ 1,250 lifetime maximum) Periodontics Prosthodontics

Annual Maximum Benefit - $1250 per person, per calendar year Affordable Premiums

Self Only Self and Family Monthly (Bank Draft Only) $ 10.70 $ 30.45 Annually $128.40 $365.40

When you join BlueLincs Dental, you select a dentist from our list of participating dentists. All covered services must be performed or authorized by the participating BlueLincs Dental dentist. Network dentists must meet and maintain rigid standards to participate in this program.

For enrollment information, call 1- 800- 722- 5675. Consult the separate Plan description for additional information.

$5,000 Accidental Death and Dismemberment

Were Giving You More Than You Asked For. Accidental Death & Dismemberment insurance

as part of your BlueLincs coverage. When you sign up for BlueLincs, you receive $5,000 in AD& D coverage.

Its one more way BlueLincs provides you extra value.

Benefits on this page are not part of the FEHB contract

How to Obtain Benefits Questions If you have a question concerning Plan benefits or how to arrange for care, contact

the Plans Membership Services Office at 1- 800- 722- 5675 or you may write them at P. O. Box 3283, Tulsa, OK 74102- 3282. You may also contact the Plan by fax at 918/ 561- 9980 or at its Website at http:// www. bcbsok. com or by email at bcbsok@ bcbsok. com.

Disputed claims review If a claim for payment or services is denied by the Plan, you must ask the Plan, in writing and within six months of the date of the denial, to reconsider its denial 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 Plan an opportunity to reconsider your claim. Your written request to the Plan must state why, based on specific benefit provisions in this brochure, you believe the denied claim for payment or service should have been paid or provided.

Within 30 days after receipt of your request for reconsideration, the Plan must affirm the denial in writing to you, pay the claim, provide the service, or request additional information reasonably necessary to make a determination. If the Plan asks a provider for information it will send you a copy of this request at the same time. The Plan has 30 days after receiving the information to give its decision. If this information is not supplied within 60 days, the Plan will base its decision on the information it has on hand.

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

You must also ask OPM for a review if the Plan fails to respond within 30 days of your written request for reconsideration or 30 days after you have supplied additional information to the Plan. In this case, OPM must receive a request for review within 120 days of your request to the Plan for reconsideration or of the date you were notified that the Plan 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 claimants 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 denied claim for payment or service should have been paid or provided. If the Plan 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 Plan requesting reconsideration; A copy of the Plans reconsideration decision (if the Plan failed to respond, provide instead (a) the date of your request to the Plan or (b) the dates the Plan requested and you provided additional information to the Plan);

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

Your daytime phone number. Medical documentation received from you or the Plan 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 IV, P. O. Box 436, Washington, DC 20044.

How to Obtain Benefits continued

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 Plans 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 Plans 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 Plans 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 Plan to determine if the Plan has acted properly in denying you the payment or service, and the information so collected may be disclosed to you and/ or the Plan in support of OPMs decision on the disputed claim.

Program- Wide Changes

Several changes have been made to comply with the Presidents mandate to implement the recommendations of the Patient Bill of Rights.

If you have a chronic, complex or serious medical condition that causes you to frequently see a Plan specialist, your primary care doctor will develop a treatment plan with you and your health plan that allows an adequate number of direct access visits with that specialist, without the need to obtain further referrals (See page 7 for details). A medical emergency is defined as the sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability, and requires immediate medical or surgical care (See page 16). The diagnosis, evaluation and medical management of certain mental conditions will be covered under this Plans Medical and Surgical Benefits provisions. Examples include attention deficit disorder and Gilles de la Touretts syndrome. Related drug costs will be covered under this Plans Prescription Drug Benefits, and any costs for psychological testing or psychotherapy will be covered under this Plans Mental Conditions Benefits.

How BlueLincs Changes January 1999

None 22

Summary of Benefits for BlueLincs - 1999

Do not rely on this chart alone. All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set forth in the brochure. This chart merely summarizes certain important expenses covered by the Plan. If you wish to enroll or change your enrollment in this Plan, be sure to indicate the correct enrollment code on your enrollment form (codes appear on the cover of this brochure). ALL SERVICES COVERED UNDER THIS PLAN, WITH THE EXCEPTION OF EMERGENCY CARE, ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS.

Benefits Plan pays/ provides Page Inpatient Hospital Comprehensive range of medical and surgical services without

care dollar or day limit. Includes in- hospital doctor care, room and board, general nursing care, private room and private nursing care, if medically necessary, diagnostic tests, drugs and medical supplies, use of operating room, intensive care and complete maternity care.

You pay a $5 copay per in hospital doctor visit. . . . . . . . . . . . . . . . . . . . . . . . .15

Extended care All necessary services, no dollar or day limit. You pay nothing. . . . . . . . . . . .15

Mental Diagnosis and treatment of acute psychiatric conditions for up to 30

conditions days of inpatient care per year. You pay nothing . . . . . . . . . . . . . . . . . . . . . . . .17

Substance Covered under Mental conditions benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

abuse Outpatient Comprehensive range of services such as diagnosis and treatment of

care illness or injury, including specialists care; preventive care, including well baby care, periodic check- ups and routine immunizations; laboratory tests and X- rays; complete maternity care. You pay $5 per office visit; $5 per house call by a doctor . . . . . . . . . . . . . . . . . . . . . . . . . . .12

Home health All necessary visits by nurses and health aides. You pay nothing . . . . . . . . . . .13

care Mental Up to 40 outpatient visits per year. You pay a $20 copay per

conditions outpatient visit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

Substance Covered under Mental conditions benefit . . . . . . . . . . . . . . . . . . . . . . . . . . . . .17

abuse Emergency care Reasonable charges for services and supplies required because of a

medical emergency. You pay a $50 copay to the hospital for each emergency room visit and any charges for services that are not covered benefits of the Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .16

Prescription drugs Drugs prescribed by a Plan doctor and obtained at a participating pharmacy. You pay $5 for Generic drugs and $10 for Name Brand drugs per prescription unit or refill . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18

Dental care Accidental injury benefit only. You pay nothing . . . . . . . . . . . . . . . . . . . . . . . .18

Vision care No current benefit

Out- of- pocket maximum Copayments are required for a few benefits; however, after your out- of- pocket expenses reach a maximum of $1,000 per Self Only or $3,000 per Self and Family enrollment per calendar year, covered benefits will be provided at 100%. This copay maximum does not include prescription drugs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8

Authorized for Distribution by the:

1999 Rate information for BlueLincs HMO

FEHB Benefits of this Plan are described in brochure 73- 267 The 1999 rates for this Plan follow.

Non- Postal rates apply to most non- Postal enrollees. If you are in a special enrollment category, refer to an FEHB Guide for that category or contact the agency that maintains your health benefits enrollment.

Postal rates apply to most career U. S. Postal Service employees, but, do not apply to non- career Postal employees, Postal retirees, certain special Postal employment categories or associate members of any Postal employees organization. If you are in a special Postal employment category, refer to the FEHB Guide for that category.

R1 - 73- 267 BlueLincs HMO 24

Non- Postal Premium Postal Premium Biweekly Monthly Biweekly Type of Code Govt Your Govt Your USPS Your Enrollment Share Share Share Share Share Share

Self Only N51 $ 64.15 $21.38 $138.99 $ 46.33 $ 75.91 $ 9.62 Self and Family N52 $150.19 $50.06 $325.41 $108.47 $177.72 $22.53