CapitalCare1999

CapitalCare, Inc.

RI 73- 718

1999 For changesin benefitssee page 22.

United States Office of Personnel Management

Authorized for distribution by the:

A Health Maintenance Organization Serving: Enrollment in this Plan is limited; see pages 9- 10 for requirements.

Enrollment Code: 2G1 Self Only 2G2 Self and Family

Service Area: Services from Plan providers are available only in the areas described on pages 9- 10.

Visit the OPM website at http:// www. opm. gov/ insure and This Plans website at http:// www. bcbsnca. com

CapitalCare

CapitalCare, Inc. has entered into a contract (CS 2797) 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 CapitalCare, 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............................................................................................................................... 3

General Information ........................................................................................................................................................ 3- 6

Confidentiality; If you are a new member; If you are hospitalized; Your responsibility; Things to keep in mind; Coverage after enrollment ends (Former spouse coverage; Temporary continuation of coverage; Conversion to individual coverage; Certificate of creditable coverage;)

Facts about this Plan ..................................................................................................................................................... 7- 10

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

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

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

General Exclusions ............................................................................................................................................................ 11 Benefits .......................................................................................................................................................................... 12- 17

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

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

Vision care

Non- FEHB Benefits ............................................................................................................................................................ 19 How to Obtain Benefits ............................................................................................................................................... 20- 21 How CapitalCare Inc. Health Benefit Changes January 1999 ................................................................................... 22 Summary of Benefits ............................................................................................................................ Inside Back Cover Rate Information ............................................................................................................................................... Back Cover

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 202/ 479- 3708 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

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.

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 for services provided or arranged by a Plan doctor except in the case of emergency as described on pages 15- 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 below.

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.

Confidentialty If you are a new member

General Information continued

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.

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.

The benefits in this brochure are effective on January 1 for those 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 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.

If you are hospitalized

Your responsibility

Things to keep in mind

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 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).

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:

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.

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 non- group 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 non- group 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.

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.

Coverage after enrollment ends

Former spouse coverage

Temporary continuation of coverage (TCC)

Notification and election requirements

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.

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, non- group 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.

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.

Conversion to individual coverage

Certificate of Creditable Coverage

Facts about this Plan

CapitalCare 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 or arranges 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 emphasizes 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.

You are covered for emergency or urgent care when you travel. Contact the 24 hour emergency assistance line, FirstHelp, at 800/ 535- 9700.

All carriers in the FEHB Program must provide certain information to you. If you did not receive information about this Plan, you can obtain it by calling the Carrier at 1 800/ 680- 9495 or 202- 479- 3708. You may write the Carrier at BCBSNCA 550 12th ST., S. W., Washington, D. C. 20065. You may also contact the Carrier by fax at 202- 479- 1300 or at its website at http:// www. bcbsnca. com or by e- mail at bcbsnca. com.

Information that must be made available to you include: Disenrollment rates for 1997. Compliance with State and Federal licensing or certification requirements 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. CapitalCare is an Individual Practice Association (IPA) model HMO in which you receive care from a network of physicians practicing in their private offices. The CapitalCare network consists of 38 hospitals, over 1,340 primary care doctors and over 3,814 specialists at more than 10,000 locations. In addition, CapitalCare has plan designated facilities for diagnostic radiology and laboratory services. Each member may choose his or her own primary care doctor from the CapitalCare Provider Directory.

CapitalCare contracts with Health Management Strategies (HMS) to administer mental health and substance abuse benefits. If you think you are in need of mental health or substance abuse services, you must first call HMS at 703/ 739- 2434 or 800/ 822- 4614. When treatment is necessary, HMS will refer you to one of their network providers. All mental health and substance abuse services must be coordinated through HMS, rather than through your primary care doctor.

The first and most important decision each member must make is the selection of a primary care physician. 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 physician 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 physician with the following exceptions: a woman may see her Plan obstetrician/ gynecologist for her annual routine examination without a referral members may receive routine vision examinations at a participating vision center without a referral, (A referral is required for ophthalmologists services), and mental health/ substance abuse services.

Information you have a right to know

Who provides care to Plan members?

Role of a primary care doctor

Facts about this Plan continued

The CapitalCare Provider Directory, also available on the website, lists primary care physicians (family practitioners, general practitioners, pediatricians and internists), with their locations and phone numbers, and notes if the doctor is available to new CapitalCare patients. Directories are updated twice a year and are available at the time of enrollment or upon request by calling the Customer Service Department at 800/ 680- 9495 or 202/ 479- 3708; you can also find out if your doctor participates with this Plan by calling this number. 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.

Upon enrollment, please select a primary care physician for yourself and each member of your family by completing and sending the selection form, included in the CapitalCare Provider Directory, to CapitalCare.

If you later decide you would like to change doctors, you may do so by calling CapitalCare. If you need help choosing a doctor, call the Plan or use the website, it is updated to give information on how to pick a PCP. Members may change their doctor selection by notifying the Plan. If the change is requested prior to the 20th of the current month, it will be effective on the first of the following month. Requests received after the 20th of the current month will be processed for the first of the second month following (e. g., a request received January 21st will be effective March 1st).

If you are receiving services from a doctor who leaves the Plan, the Plan will notify you in advance of the doctors participation status with the Plan and refer you to another doctor within the Plan.

Except in a medical emergency, or when a primary care physician has designated another doctor to see his or her patients, you must receive a referral from your primary care physician before seeing any other physician or obtaining special services. Referral to a participating specialist is given at the primary care physicians discretion; if non- Plan specialists or consultants are required, the primary care physician will arrange appropriate referrals through the Plan.

When you receive a referral from your primary care physician, it usually covers up to a maximum of three visits. All follow- up care must be provided or authorized by the primary care physician. Always ask your primary care physician to explain the number of authorized visits at the time the referral is written.

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.

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 primary care physician is responsible for obtaining authorization from CapitalCare before you may be hospitalized.

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 physician for the care to be covered by the Plan. If the doctor who originally referred you to this specialist is now your Plan primary care physician, 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 physician and want to continue with this specialist, you must schedule an appointment so that the primary care physician can decide whether to treat the condition directly or refer you back to the specialist.

If you require hospitalization, your primary care physician or authorized specialist will make the necessary arrangements and continue to supervise your care.

Choosing your doctor Referrals for specialty care

Authorizations For new members

Hospital care

Facts about this Plan continued

Members are responsible for payment of copayments at the time the services are received. The Maximum Annual Copayment is $2,000 per calendar year for Self- Only coverage or $6,000 per calendar year for Family coverage. We will notify you if your copayment maximum is reached, based on billing and claims information in our records. If you satisfy the copayment maximum, you will not be required to pay additional copayments for services which are subject to the copayment maximum, for the remainder of that calendar year. The Maximum Annual Copayment limit does not apply to member charges or copayments for covered services in connection with any of the following: prescription drug and vision care copays.

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 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.

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

A drug or medical treatment or procedure is experimental or investigational: 1. if the drug or device cannot be lawfully marketed without approval of the U. S. Food and

Drug Administration and approval for marketing has not been given at the time the drug or device is furnished 2. if reliable evidence shows that drug, device or medical treatment or procedure is the subject

of ongoing phase I, II, or III clinical trails or under study to determine its maximum tolerated dose, its toxicity, its safety, its efficacy, or its efficacy as compared with a standard means of treatment or diagnosis 3. if reliable evidence shows that the consensus of opinion among experts regarding the drug,

device or medical treatment or procedure is that further studies or clinical trails are necessary to determine its maximum tolerated dose, its toxicity, its safety, its efficacy or its efficacy as compared with a standard means of treatment or diagnosis

Reliable evidence shall mean only published reports and articles in the authoritative medical and scientific literature; the written protocol or protocols used by the treating facility or the protocol( s) of another facility studying substantially the same drug, device or medical treatment or procedure; or the written informed consent used by the training facility or by another facility studying substantially the same drug, device or medical treatment or procedure.

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

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 this Plan. Benefits for care outside the service area are limited to emergency services, as described on pages 15- 16.

If you or a covered family member move outside the service area, 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.

The service area for this plan includes the following areas: The District of Columbia; the Maryland counties of Calvert, Howard, Montgomery, and Prince Georges, and portions of the Maryland counties of Anne Arundel, Carroll, Charles, Frederick and St. Marys within the zip codes listed below; the Virginia counties of Arlington, Fairfax, Fauquier, Londoun, Prince William, Spotsylvania, and Stafford, plus the cities of Alexandria, Falls Church and Fredericksburg.

Deductible carryover Submit claims promptly

Experimental/ investigational determinations

Other considerations The Plans service area Out- of- pocket

maximum

Facts about this Plan continued

Anne Arundel: 20711, 20724, 20733, 20751, 20754- 5, 20758, 21764- 5, 20776, 20778- 9, 20794, 21032, 21035, 21037, 21054, 21060- 2, 21076- 7, 21090, 21098, 21106, 21108, 21113- 4, 21140, 21144, 21225, 21240, 21401- 5, 21411- 12

Carroll: 21080, 21104, 21764, 21771, 21776, 21784, 21791- 2, 21797 Charles: 20601- 4, 20607, 20611- 13, 20616- 17, 20622, 20632, 20637, 20640, 20643, 20646, 20658, 20662, 20675, 20677, 20693, 20695

Frederick: 21701- 2, 21703, 21704, 21705, 21709- 10, 21714- 18, 21736, 21754- 59, 21762, 21769- 71, 21773- 78, 21788, 21790- 91, 21792, 21793, 21798

St. Marys: 20622, 20635, 20659- 60. 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.

In the event of major disaster, epidemic, war, riot, civil insurrection, disability of a significant number of Plan providers, complete or partial destruction of facilities, or other 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.

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 Plan and complete all necessary documents and authorizations requested by the Plan.

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 not cover services, except those for emergencies, unless you use Plan providers. 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.

This coordination of benefits (double coverage) provision 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 Plan.

When there is double coverage for covered benefits, other than emergency services from nonPlan 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: (1) its benefits in full or (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.

General Limitations Important notice

Circumstances beyond Plan control

Other sources of benefits

Medicare Group health insurance and automobile insurance The Plans

service area

continued

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 care provider must authorize all care. See your CHAMPUS Health Benefits Advisor if you have questions about CHAMPUS coverage.

If you are covered by both this Plan and Medicaid, this Plan will pay benefits first. The Plan will not pay for 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, 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).

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.

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

If a covered person is sick or injured as a result of the act or omission of another person or party, the Plan requires that it be reimbursed for the benefits provided in 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 Limitations continued

CHAMPUS Medicaid Workers compensation

DVA facilities, DoD facilities, and Indian Health Service

Other Government agencies

Liability insurance and third party actions

General Exclusions

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 the result of an act of rape or incest.

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 described under Authorizations on page 8. The following are excluded:

Medical and Surgical Benefits

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 for primary care or a $10 copay per visit to a specialist, but no additional copay for laboratory tests and X- rays received at an approved facility. 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.

The following services are included and are subject to the office visit copay unless stated otherwise: Preventive care, including well- baby care and periodic check- ups, and hearing screening for

children under age 18 (hearing exams for adults are covered only when referred by the primary care doctor) Routine Screening Mammograms are covered at a minimum as follows: for women age 35

through age 39, one mammogram during these five years; for women age 40 through 49, one mammogram every one or two years; for women age 50 through 64, one mammogram every year; and for women age 65 and above, one mammogram every two years. In addition to routine screening, diagnostic mammograms are covered when prescribed by the doctor as medically necessary Routine immunizations and boosters - except for travel Consultations by specialists Diagnostic procedures, such as laboratory tests and X- rays rendered by a Plan facility, are

covered in full Complete obstetrical (maternity) care for all covered females, including prenatal, delivery and

postnatal care by a Plan doctor. A $10 copayment per visit applies with a $100 copayment maximum per pregnancy. 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 and family planning services Diagnosis and treatment of diseases of the eye A $25 copayment per visit applies for Allergy testing and treatment, including testing and

treatment materials (such as allergy serum) The insertion of internal prosthetic devices, such as pacemakers and artificial joints, including

the cost of the device; Implantable drugs. Dental implants are not covered. Cornea, heart, heart/ lung, lung (single and double), kidney and liver; Allogeneic (donor)

Bone Marrow transplants for the following conditions: acute lymphocytic or non- lymphocytic leukemia, advanced Hodgkins lymphoma, advanced non- Hodgkins lymphoma, advanced neuroblastoma, aplastic anemia, severe combined immunodeficiency, Wiscott- Aldrich Syndrome, infantile malignant osteopetrosis (Albers- Schonberg disease or marble bone disease), chronic myelogenous leukemia (CML); homozygous beta thalassemia (thalassemia major) and pancreas. Autologous Bone Marrow (autologous stem cell/ peripheral stem cell support) for the following conditions: acute lymphocytic leukemia 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. Autologous Bone Marrow/ peripheral stem cell Treatment for breast cancer, multiple myeloma and epithelial ovarian cancer may be provided in a non- randomized plan approved clinical trial.

Transplants are covered when prior authorization is obtained from CapitalCare. Related medical and hospital expenses of the donor are covered when the recipient is covered by this Plan and only to the extent that the services are not covered under any other health insurance plan or contract.

CARE MUST BE RECEIVED FROM OR ARRANGED BY YOUR PRIMARY CARE PHYSICIAN What is covered

Medical and Surgical Benefits continued

CARE MUST BE RECEIVED FROM OR ARRANGED BY YOUR PRIMARY CARE PHYSICIAN

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. Dialysis Chemotherapy, radiation therapy, and inhalation therapy Surgical treatment of morbid obesity Norplant, Depo Provera and IUDs Home health services of skilled providers, including intravenous fluids and medications, when

prescribed by your Plan doctor, who will periodically review the program for continuing appropriateness and need All necessary medical or surgical care in a hospital or extended care facility from Plan

doctors and other Plan providers, at no additional cost to you Blood and blood derivatives not replaced by the member

Oral and maxillofacial surgery is provided for non- dental 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 any dental care involved in the treatment of temporomandibular 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 two consecutive months per condition if significant improvement can be expected within 90 days; you pay $20 per outpatient session. 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.

Diagnosis and certain treatment of treatment options infertility is covered; you pay a $5 primary care or a $10 specialist copay. The following types of artificial insemination are covered; intravaginal insemination (IVI); intracervical insemination (ICI) and Intrauterine insemination (IUI); you pay a $10 specialist copay; cost of donor sperm is not covered. Certain fertility drugs are covered under the Prescription Drug Benefit. Other assisted reproductive technology (ART) procedures, such as in vitro fertilization and embryo transfer, are not covered.

Dental implants Physical examinations that are not necessary for the prevention and detection of disease, such

as those 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 Homemaker services Hearing aids Transplants not listed as covered Long- term rehabilitative therapy Cardiac rehabilitation Orthopedic devices, such as braces; foot orthotics Prosthetic devices, such as artificial limbs and lenses following cataract removal Durable medical equipment, such as wheelchairs and hospital beds Chiropractic services Blood and blood products Treatment of obesity and weight reduction programs (except for surgery for morbid obesity) Radial keratotomy and similar surgical procedures to correct retractive error

Limited benefits What is not covered

Hospital/ Extended Care Benefits

CARE MUST BE RECEIVED FROM OR ARRANGED BY YOUR PRIMARY CARE PHYSICIAN

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. 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 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. Supportive and palliative care for a terminally ill member is covered in the home or a hospice facility. Services include inpatient and outpatient care, 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. You pay nothing.

Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor. Hospitalization for certain dental procedures is covered when a Plan doctor 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.

Hospitalization for medical treatment of substance abuse is limited to emergency 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 18 for non- medical substance abuse benefits.

Personal comfort items, such as telephone and television Custodial care, rest cures, domiciliary or convalescent care Blood and blood products

What is covered Hospital care

Extended care Hospice care Ambulance service

Limited benefits Inpatient dental procedures

Acute inpatient detoxification

What is not covered

Emergency Benefits

A medical emergency is 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. 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.

If you are in an emergency situation, please call your primary care physician. If your PCP is unavailable, call FirstHelp at 800/ 535- 9700 to receive health care advice from a registered nurse. In extreme emergencies (i. e., if life or limb are in jeopardy), 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 should 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 in a non- Plan facility, the Plan must be notified at 800/ 680- 9495 or 202- 479- 3708 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 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.

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 provided by Plan providers.

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

$25 per hospital emergency room visit, or $25 per non- participating urgent care center or $10 per participating urgent care center visit for emergency services that are covered benefits of this Plan. If the emergency room visit results in admission to a hospital, the copay is waived.

Benefits are available for any medically necessary health service that is immediately required because of injury or unforeseen illness.

If you are in an emergency situation, please contact FirstHelp at 800/ 535- 9700 to receive health care advice from a registered nurse. In extreme emergencies (i. e., if life and limb are in jeopardy), contact the local emergency system (e. g., the 911 telephone system) or go to the nearest hospital emergency room.

If you need to be hospitalized, the Plan must be notified at 800/ 680- 9495 or 202- 479- 3708 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.

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

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

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

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 determined by the Plan to be medically necessary

What is a medical emergency?

Emergencies within the service area

Plan pays . . . You pay . . .

Emergencies outside the service area

Plan pays . . . You pay . . .

What is covered

Mental Conditions/ Substance Abuse Benefits

Mental conditions What is covered

Outpatient Care Inpatient Care Partial Hospitalization (day treatment)

What is not covered Emergency Benefits continued

What is not covered Filing claims for non- Plan providers

Elective care or non- emergency care Emergency care provided outside the service area if the need for care could have been

foreseen before leaving the service area 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. Prescription drug claims must be filed with the Plan within 15 months of the date incurred.

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 pages 20- 21.

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)

Up to 40 outpatient visits to Plan doctors or other psychiatric personnel each calendar year; you pay a $25 copay for each covered visit all charges thereafter.

Up to 30 days of hospitalization each calendar year; you pay a 50% copayment all charges thereafter. A $25 copay applies for each inpatient visit, limited to one (1) per day.

Available inpatient hospital days may be exchanged for a partial outpatient hospital day at the rate of two outpatient day treatment days for each available inpatient day.

Care for psychiatric conditions that in the professional judgment of Plan doctors 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 Marital, family, educational or other counseling or training servicies

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 health 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. However, there is a 90- day inpatient hospital lifetime maximum for substance abuse.

Treatment that is not authorized by the Plan Mental Health/ Substance Abuse Utilization Management vendor.

Substance abuse What is covered

What is not covered

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Copays: Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan retail pharmacy will be dispensed for up to a 34- day supply. You pay a $5 copay for generic drugs, or a $10 copay for brand name drugs, per prescription unit or refill.

Mail Order: Covered prescription drugs may also be obtained through the Plans mail order pharmacy and will be dispensed for up to a 90- day supply. You pay a $10 copay per prescription unit or refill for generic drugs or a $20 copay per prescription unit or refill for brand name drugs.

Generic Substitution: Under both the retail and mail program, if you receive a brand name drug when a generic is available, you are responsible for the brand name copayment and the difference in cost between the brand drug and generic drug. You are not responsible for the difference in cost if the prescriber determines the brand name drug is medically necessary.

Formulary: Drugs are prescribed by Plan doctors and dispensed in accordance with the Plans drug formulary. Nonformulary drugs will be covered when prescribed by a Plan Doctor. Medications that are not on the Formulary are still covered through the prescription drug program and members do not have to pay any additional copayments. Enrollees are not held accountable for departures from formulary prescriptions.

Prior Authorization: Certain drugs require clinical prior authorization. Contact the Plan for a listing of which drugs are subject to the prior authorization policy. Prior authorization may be initiated by the Prescriber, the Pharmacy or the Member by calling PAID Prescriptions. If prior authorization is not obtained or is denied, the drug will not be covered.

There are three ways to initiate clinical prior authorization for the medications requiring prior authorization: 1. A member may request a prior authorization by calling 1- 800- 455- 8352. After the call is

received, a PAID Prescriptions pharmacist will contact the members physician to discuss the medication. 2. A physician may call the PAID Prescriptions prior authorization department at 1- 800- 458-

8001. When a member receives a prescription for one of the listed medications, he should explain to the physician that prior authorization is needed before the drug can be dispensed. 3. A member may present the prescription to their pharmacist. The pharmacist will contact the

PAID Prescriptions prior authorization department and give them the name and telephone number of the prescribing physician. The physician will then be contacted for the necessary information.

Covered medications and accessories include: Drugs for which a prescription is required by Federal law Oral contraceptive drugs; diaphragms Insulin and the following injectables; Heparin, Glucagon, Imitrex, EpiPen, and Anakit Disposable needles and syringes needed to inject covered prescribed medication Smoking deterrents, limited to one series per member per lifetime Diabetic supplies, including insulin syringes, needles, glucose test strips, lancets and alcohol

swabs Allergy serum

Intravenous fluids and medication for home use, implantable drugs (such as Norplant), some injectable drugs (such as Depo Provera), and IUDs are covered under Medical and Surgical Benefits.

Drugs to treat sexual dysfunction are subject to dosage limitations. Contact the Plan for the dosage limitations.

Drugs available without a prescription or for which there is a nonprescription 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 Drugs for cosmetic purposes Drugs to enhance athletic performance Contraceptive jellies, creams, foams or devices Diabetic testing, monitoring devices or meters Drugs for weight loss

Prescription Drug Benefit

What is covered Limited benefits

What is not covered

Other Benefits Vision care

What is covered In addition to the medical and surgical benefits provided for the diagnosis and treatment of diseases of the eye, annual eye refractions (to provide a written lens prescription) may be obtained from Plan providers. You pay a $10 copay per exam at participating vision centers or a $25 copay per exam at participating ophthalmologists (exam by an ophthalmologist requires a referral); a $48 copay for exam and three (3) follow- up fittings for daily wear contact lens exams at participating vision centers excluding the cost of the contact lenses. A $78 copay required for disposable contact lens, fitting and one year for follow up care.

Corrective lenses or frames Eye exercises

What it not covered

Non- FEHB Benefit 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 of this Plan. The cost of the benefits described in this section is not included in the FEHB premium and any charges for these services do not count toward any FEHB deductibles or out- of- pocket maximums. These benefits are not subject to the FEHB disputed claims procedure.

Wellness programs Discounts are available for the following services: fitness club memberships child care smoking cessation programs weight management programs hospital based education programs (i. e., stress management, nutrition, first

aid, health back, etc.)

Dental care What is covered The following preventive and diagnostic services are covered when provided by

Plan dentists; you pay a $14 adult copay or a $10 child copay per visit: Oral examinations Prophylaxis, or cleaning (every 6 months) Fluoride treatment Pulp Vitality tests Diagnostic casts Oral Hygiene instruction

You pay 50% of your participating dentists usual and customary fees for: X- rays Fillings Sealants

For all other non- accidental services under this program, you pay 75% of the participating dentists usual and customary fees, including: Restorations Crown and bridge services Endodontic services Periodontics Prosthodontics, removables Oral surgery services Broken appointment fee Orthodontic services TMJ treatment Cosmetic and anesthetic services

Expanded Vision Plan members are entitled to a 25% discount off retail for glasses and contact

benefits lenses.

Benefits on this page are not part of the FEHB contract

How to Obtain Benefits Questions

Disputed claims review

Plan reconsideration

OPM review

If you have a question concerning Plan benefits or how to arrange for care, contact the Plans Member Service Department at 800/ 680- 9495 or 202/ 479- 3708 or you may write to the Plan at 550 12th Street, S. W., Washington, D. C. 20065. You may contact the Plan by fax at 202- 479- 1300, at its website at http:// www. bcbsnca. com.

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.

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 initial denial.

You may 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 should 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 3, P. O. Box 436, Washington, D. C. 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.

How CapitalCare Inc. Health Benefit Changes January 1999 Program- wide Changes

Changes to this Plan

Several changes have been made to comply with the Presidents mandate to implement the recommendations for the Patient bill of Rights. (See page 7 for details)

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 specialists, without the need to obtain further referrals. (See page 8 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 pages 15- 16)

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. Office visits for the medical aspects of treatment do not count toward the outpatient Mental Conditions visit limit.

The brochure now shows a mail order option for obtaining prescription drugs that allows for up to a 90- day supply subject to a copay of $10 per prescription unit or refill for generic drugs or a $20 copay per prescription unit or refill for brand name drugs. The mail order benefit was not shown in this Plans 1998 FEHB brochure but was implemented in early 1998 with copays of $5 for generic drugs and $10 for brand name drugs.

The copay for brand name drugs obtained at a participating pharmacy is now $10 plus the cost difference between the brand name drug and its generic equivalent. Previously, the copay was simply $10. You are not responsible for the difference if there is no generic equivalent or if your doctor states the brand name is medically necessary.

Prescription Drug Benefit coverage of diabetic supplies has been extended to cover lancets and alcohol swabs, which were previously not covered.

Diaphragms are now covered. Norplant, Depo Provera, and IUDs are now covered under Medical and Surgical Benefits.

This means that the cost of these items is included in the office visit copay. Previously, these items were covered under the Prescription Drug Benefit.

The timely filing deadline for prescription drug claims is now 15 months from the date incurred. Previously, the deadline was 12 months.

Summary of Benefits for CapitalCare 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 care Hospital Comprehensive range of medical and surgical services without 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 nothing ............................................................................................................................ 14

Extended care All necessary services, no dollar or day limit. You pay nothing ................................................ 14

Mental Diagnosis and treatment of acute psychiatric conditions including the psychiatric aspects

conditions/ of substance abuse for: up to 30 days of inpatient care per year. There is a 90- day

Substance inpatient lifetime maximum for substance abuse. You pay 50% copayment .............................. 16

abuse

Comprehensive range of services such as diagnosis and treatment of 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 a $5 PCP copay per office visit or $10 specialist copay ($ 100 copayment maximum per pregnancy); nothing for labs and x- rays rendered by a Plan approved facility ........................................................................................................................................ 12- 13

Home All necessary visits by a home health agency. You pay nothing ................................................ 14

health care Mental Up to 40 outpatient visits per year. You pay a $25 copay per visit ............................................ 16

conditions/ Substance abuse

Emergency care Reasonable charges for services and supplies required because of a medical emergency.

You pay a $25 copay to the hospital for each emergency room visit and any charges for services that are not covered by this Plan .......................................................................... 15- 16

Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy. Medications are covered through participating retail pharmacies and through the mail service program. At the retail pharmacy, you pay a $5 generic or $10 brand name copay per prescription unit or refill for a 34- day supply. At the mail service pharmacy, you pay

a $10 generic or $20 brand name copay per prescription for a 90- day supply ........................... 17

Dental care No current benefit

Vision care Annual routine exam. You pay a $10 copay per visit at participating vision care centers; $25 at participating ophthalmologist offices (requires referral) ...................................... 19

Out- of- pocket maximum Copayments are required for a few benefits; however, after your out- of- pocket expenses reach a maximum of $2,000 per Self Only or $6,000 per Self and Family enrollment per calendar year, covered benefits will be provided at 100%. This copay maximum does not include charges for prescription drugs and vision care benefits .................... 9

Outpatient care

Authorized for Distribution by the:

United States Office of Personnel Management

Non- Postal rates apply to most non- Postal enrollees. If you are in a special enrollment category, refer to the 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 employee organization. If you are in a special Postal employment category, refer to the FEHB Guide for that category

1999 Rate Information for CapitalCare, Inc.

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

High Option Self Only 2G1 $ 72.06 $ 26.23 $156.13 $ 56.83 $ 84.98 $13.31

High Option Self and Family 2G2 $160.39 $109.92 $347.51 $238.16 $183.29 $87. 02