Pages 1--64 from Microsoft Word - Brochure Y2K.doc

A Fee for Service Plan with a Preferred Provider Organization and a Point of Service Product
Administered by the Blue Cross and Blue Shield Association

Who may enroll in this Plan All Federal employees and annuitants who are eligible to enroll in the FEHBP
Enrollment code for this Plan
101 High Option Self Only
102 High Option Self and Family
104 Standard Option Self Only
105 Standard Option Self and Family

Visit the OPM website at http www opm gov insure
and
our website at http www fepblue org

Authorized for distribution by the
United States Office of
Personnel Management
Retirement and
Insurance Service

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Blue Cross and Blue Shield Service Benefit Plan 2000
Table of Contents
Introduction 3

Plain Language 3
How to use this brochure 3
Section 1 Fee for Service Plans 4
Section 2 How we change for 2000 4
Section 3 How to get benefits 6
Section 4 What if we deny your claim or request for pre authorization 12
Section 5 Benefits 15
Section 6 How to file a claim 39
Section 7 General exclusions Things we don't cover 41
Section 8 Limitations Rules that affect your benefits 42
Section 9 Fee for Service Facts 47
Section 10 FEHB Facts 55
Department of Defense FEHB Demonstration Project 58
Inspector General Advisory Stop Health Care Fraud 59
Index 60
Summary of benefits 62
Premiums 64

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Blue Cross and Blue Shield Service Benefit Plan 2000
Introduction
Blue Cross and Blue Shield Service Benefit Plan
This brochure describes the benefits you can receive from the Blue Cross and Blue Shield Service Benefit Plan under its contract CS 1039 with the Office of Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law This

Plan is underwritten by Participating Blue Cross and Blue Shield Plans which administer this Plan on behalf of the Blue Cross and Blue Shield Association and are referred to as Local Plans in this brochure

This brochure is the official statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this brochure If you are enrolled for Self and Family coverage each eligible family member is also entitled to these
benefits Nothing anyone says can modify or otherwise affect the benefits limitations and exclusions of this brochure
Because OPM negotiates benefits and premiums annually they change each year This brochure describes the only benefits available to you under this Plan in 2000 Benefit changes are effective January 1 2000 and are shown on pages 4 5 You do not have a right to

benefits that were available before January 1 2000 unless those benefits are also contained in this brochure Premiums are listed at the end of this brochure

Plain language
The President and Vice President are making the Government's communication more responsive accessible and understandable to the public by requiring agencies to use plain language Health plan representatives and Office of Personnel Management staff have worked
cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary technical terms you and other personal pronouns active voice and short sentences

We refer to the Blue Cross and Blue Shield Service Benefit Plan as this Plan throughout this brochure even though in other legal documents you will see a plan referred to as a carrier
Sections one two four and ten are now in plain language as well as portions of sections three and eight We will rewrite the remaining sections of this brochure including the benefits section for year 2001 Please note that the format and organization of this brochure
have changed as well
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable

How to use this brochure
This brochure has ten sections Each section has important information you should read If you want to compare this Plan's benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make
comparisons easier
1 Fee for Service Plans FFS This Plan is a FFS plan Turn to this section for a brief description of Fee for Service plans and how they work

2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get benefits and how we operate
4 What if we deny your claim or request for pre authorization This section tells you what to do if you disagree with our decision not to pay for your claim or to deny your request for a service

5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find information about non FEHB benefits
6 How to file a claim Look here to find specific information on how to file claims with us
7 General exclusions Things we don't cover Look here to see benefits that we will not provide
8 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
9 Fee for Service Facts This section contains information about precertification protection against catastrophic expenses and a definitions section

10 FEHB Facts Read this for information about the Federal Employees Health Benefits FEHB Program

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Blue Cross and Blue Shield Service Benefit Plan 2000
Section 1 Fee for Service Plans
Fee for Service plans reimburse you or your provider for covered services They do not typically provide or arrange for health care Fee for Service plans let you choose your own physicians hospitals and other health care providers

The FFS plan reimburses you for your health care expenses usually on a percentage basis These percentages as well as deductibles methods for applying deductibles to families and the percentage of coinsurance you must pay vary by plan The type and extent of
covered services vary by plan There is a detailed explanation of the benefits we offer in this brochure you should read it carefully
This FFS plan offers a Preferred provider organization PPO arrangement This arrangement with health care providers gives you enhanced benefits or limits your out of pocket expenses

Section 2 How we change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copayment of 10 for all primary care office visits
changes This year you have a right to more information about this Plan care management our networks
facilities and providers
If you have a chronic or disabling condition or are in the second or third trimester of pregnancy and your provider is leaving our PPO network at our request without cause we will notify you You may

continue to receive our PPO level of benefits for your specialist's services for up to 90 days after you receive notice We will provide regular non PPO benefits for the specialist's services after the
90 day period expires
You may review and obtain copies of your medical records on request If you want copies of your medical records ask your health care provider for them You may ask that a physician amend a

record that is not accurate not relevant or incomplete If the physician does not amend your record you may add a brief statement to it If they do not provide you your records call us and we will
assist you
If you are over age 50 all FEHB plans cover a screening sigmoidoscopy every five years This screening is for colorectal cancer

Changes to this Your share of the High Option Blue Cross and Blue Shield Service Benefit Plan premium will increase by 4.3 for Self Only or 3.6 for Self and Family
Plan Your share of the Standard Option Blue Cross and Blue Shield Service Benefit Plan premium will
increase by 8.0 for Self Only or 7.2 for Self and Family
We have eliminated the 50 prescription drug deductible applicable to drugs obtained from retail pharmacies under both options

We no longer waive the copayment for prescription drugs obtained through the mail for members with Medicare Part B as primary payer Under High Option all members now pay 8 for generic
and 14 for brand name prescription drugs and supplies obtained through the Mail Service Prescription Drug Program Under Standard Option all members now pay 12 for generic and
20 for brand name prescription drugs and supplies obtained through the mail See pages 34 35
Under High Option we no longer waive or reduce the coinsurance for prescription drugs obtained from a retail pharmacy for members with Medicare Part B as primary payer and all members will

pay 15 PPA at Preferred retail pharmacies and 35 AWP at Non preferred retail pharmacies Previously when Medicare Part B was the primary payer the 15 PPA coinsurance at Preferred
pharmacies was waived and the 35 AWP coinsurance at Non preferred pharmacies was reduced to 15 AWP See pages 34 35

Under Standard Option you now pay 25 PPA at Preferred retail pharmacies and 45 AWP at Non preferred retail pharmacies Previously coinsurance was 20 PPA at Preferred retail
pharmacies and 40 AWP at Non preferred retail pharmacies See pages 34 35
Under Standard Option we no longer waive or reduce the coinsurance for prescription drugs obtained from a retail pharmacy for members with Medicare Part B as primary payer who are

confined to a nursing home Previously the 20 PPA coinsurance at Preferred retail pharmacies was waived and the 40 AWP coinsurance at Non preferred retail pharmacies was reduced to 20
AWP See pages 34 35

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Blue Cross and Blue Shield Service Benefit Plan 2000
Under Standard Option you now pay 10 PPA after the 200 calendar year deductible for covered professional services rendered by Preferred providers Obstetrical care rendered by
Preferred providers will continue to be paid in full Previously your coinsurance was 5 PPA for these services See pages 16 17 and 27

You now pay nothing after the associated office visit copayment for diagnostic and screening sigmoidoscopies when rendered by Preferred facilities or Preferred professionals on an outpatient
basis When rendered by Non preferred facilities or Non preferred professionals benefits will be provided under Other Medical Benefits for one screening sigmoidoscopy every five years at age 50
or over the visit charge associated with these screening sigmoidoscopies is not covered and for all medically necessary diagnostic sigmoidoscopies See pages 26 28 and 31

Coverage is now available for certain organ tissue transplant procedures for chronic lymphocytic leukemia and indolent or non advanced small cell lymphocytic lymphoma only when performed as
part of a clinical trial See pages 18 and 19
Under this Plan's Standard Option Point of Service POS program you now pay 10 for home office and clinic visits This includes the copayments for home visits during covered home health

care by nurses or home health aides as well as outpatient physical occupational and speech therapy Previously your copayment was 5 for these services See the POS addendum for your service area
for details
Under this Plan's Standard Option Point of Service POS program you now pay a 5 generic or a 15 brand name copayment for prescription drugs and supplies when you use a POS retail

pharmacy You now pay a 12 generic or a 20 brand name copayment for each prescription drug or refill when you use the mail service pharmacy Previously your copayments were 5 per generic
and 10 per brand name prescription obtained from a POS retail pharmacy and 12 per prescription obtained through the mail See the POS addendum for your service area for details

Mail Service Prescription Drug Program copayments are now included under the Catastrophic Protection Benefit as out of pocket expenses See page 49
Coverage is now available for diabetic education See page 29
Coverage is now available for immunizations for Lyme disease and Hepatitis See pages 26 28 and 31

Coverage is now available for cardiac rehabilitation services through case management under the flexible benefits option See pages 6 and 41
See pages 10 and 11 for additional information concerning Local Plans that do not have Participating providers or Member hospitals
The benefit descriptions on pages 15 35 now indicate what you pay

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Blue Cross and Blue Shield Service Benefit Plan 2000
Section 3 How to get benefits
How do I keep my
health care
expenses down FEHB plans are expected to manage their costs prudently All FEHB plans have cost containment You can help measures in place All fee for service plans include two specific provisions in their benefits
packages precertification of inpatient admissions and the flexible benefits option Some include managed care options such as PPO's to help contain costs

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

Precertification Precertification evaluates the medical necessity of proposed admissions and the number of days required to treat your condition You are responsible for ensuring that the precertification
requirement is met except for routine maternity admissions You or your doctor must check with your Local Plan before being admitted to the hospital If that doesn't happen your Plan will reduce

benefits by 500 Be a responsible consumer Be aware of your Plan's cost containment provisions You can avoid penalties and help keep premiums under control by following the procedures
specified on pages 47 48 of this brochure
Flexible benefits Under the flexible benefits option the Local Plan has the authority to determine the most effective
option way to provide services The Local Plan may identify medically appropriate alternatives to traditional care and coordinate the provision of Plan benefits as a less costly alternative benefit

Alternative benefits are subject to ongoing review The Local Plan may decide to resume regular contract benefits at its sole discretion Approval of an alternative benefit is not a guarantee of any

future alternative benefits The decision to offer an alternative benefit is solely the Local Plan's and may be withdrawn at any time It is not subject to OPM review under the disputed claims process

PPO and Point of
Service POS PPO This Plan has established Preferred provider organization PPO arrangements You can receive

covered services from PPO providers at a reduced cost Be sure to look to see if there are PPO cost savings when you review the benefits described in this brochure The Local Plan or for pharmacies
PCS Health Systems Inc is solely responsible for the selection of PPO providers and any questions regarding PPO providers should be directed to the Local Plan or for pharmacies PCS Health
Systems Inc see pages 10 11 and 54 for more information Call your Local Plan to obtain the names of PPO providers and to verify continued participation as a PPO provider

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

POS This Plan offers a Point of Service POS program under Standard Option in the following Local Plan areas Connecticut Georgia Kansas Louisiana New Orleans area Massachusetts Minnesota
New Jersey New York areas served by the Empire Plan North Dakota Fargo area Ohio Cincinnati area and Oklahoma The POS program provides a higher level of benefits when

services are provided or referred by a primary care physician selected by the member while providing Standard Option Non preferred benefits for services received without a referral An
addendum and a POS selection form are available from the Local Plans in the areas noted above that outline service areas benefit levels and special requirements of the POS program

How much do I pay You must share the cost of some services These cost sharing measures include deductibles coinsurance and copayments These and other measures are described in more detail below
for services

Deductibles A deductible is the amount of expense you must incur for covered services and supplies before the Plan starts paying benefits for the expense involved A deductible is not reimbursable by the Plan
and benefits paid by the Plan do not count toward a deductible When a benefit is subject to a deductible only expenses allowable under that benefit count toward the deductible

Calendar year The calendar year deductible is the amount of expenses you must incur for covered services and supplies each calendar year before the Plan pays certain benefits The calendar year deductible is
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Blue Cross and Blue Shield Service Benefit Plan 2000
150 per person under High Option and 200 per person under Standard Option The calendar year deductible applies to all covered services and supplies except for certain Inpatient Hospital
Benefits Facility Benefits Outpatient Surgery Additional Benefits Prescription Drug Benefits Standard Option Dental Benefits or under High Option Surgical Benefits and Maternity
Benefits
If the Billed charge for services you receive is less than the remaining portion of your deductible you pay the Billed charge If the Billed charge is more than the remaining portion of your

deductible you pay the remaining portion and you and the Plan pay the stated percentage of the amount of the Covered charge remaining if any see the discussion of coinsurance below

If you change options in this Plan during the calendar year the amount of covered expenses already applied toward the deductible of your old option will be credited to the deductible of your new
option
Hospital admission The per admission deductible is the amount of covered hospital room and board expenses you must incur during each Non preferred hospital admission before the Plan pays benefits The per
admission deductible is 100 under High Option and 250 under Standard Option
Family limit There is a separate calendar year deductible of 150 per person under High Option and 200 per person under Standard Option Under a family enrollment the deductible is considered satisfied
and benefits are payable for all family members when the combined covered expenses applied to the calendar year deductible for family members reach 300 under High Option and 400 under

Standard Option
Coinsurance Coinsurance is the stated percentage of Covered charges you must pay after you have met any applicable deductibles The Plan will base this percentage on either the Billed charge or the
Allowable charge whichever is less For instance when under Standard Option this Plan pays 75 of the Allowable charge see Definitions for a covered service you are responsible for the

coinsurance which is 25 of the Allowable charge In addition you will be responsible for any excess charge over the Plan's Allowable charge when you use a Non participating physician or
pharmacy For example if a Non participating physician ordinarily charges 100 for a service but the Plan's Allowable charge NPA is 65 determined by using the greater of the Medicare
participating fee schedule amount for the service 65 or 80 of the Plan's usual customary and reasonable amount 80 of 80 64 the Plan will pay 75 of the Allowable charge 75 of
65 48.75 You must pay the 25 coinsurance of the Allowable charge 16.25 plus the difference between the Billed charge and the Allowable charge 35 for a total member
responsibility of 51.25
Remember if you use Preferred or Participating physicians and pharmacies your share of Covered charges after meeting any deductible is limited to the stated coinsurance amounts based on the

Allowable charge in most Local Plan areas see pages 10 and 11 for exceptions If you use Nonparticipating physicians or pharmacies your out of pocket costs will be higher as shown in the
example above
Your local Blue Cross and Blue Shield Plan negotiates payment arrangements with Preferred and Member hospitals and other facilities and with Preferred and Participating physicians and other

professional providers that result in overall cost containment The amounts these providers agree to accept as payment in full are generally but not always lower than the Billed charge see Definitions
for an explanation of Preferred and Member rates Preferred and Participating Provider Allowances and Billed charge under Covered charges For services of these providers your coinsurance will be
based on the lesser of the Billed charge or the negotiated amount that these providers have agreed to accept including any savings the Local Plan realizes through discounts that are known and that can
be accurately calculated at the time your claim is processed If you are age 65 or older and not enrolled in Medicare this may not apply see pages 46 and 47 If you use Non member facilities
for inpatient care the Plan will pay its percentage based on the Billed charge or Average charge see Definitions under Covered charges You will be responsible for the coinsurance calculated on the
Billed charge or Average charge and any excess charge over the Average charge
Copayments A copayment is the stated amount the Plan may require you to pay for a covered service such as 12 per generic prescription by mail or 12 per office visit charge at a Preferred physician For instance
when you visit a Preferred physician for a covered service after you pay the 12 copayment the Plan pays the remainder of the Preferred Provider Allowance PPA

For outpatient facility care and inpatient and outpatient mental conditions substance abuse care in Preferred and Member hospitals you are responsible for the least of the sum of the applicable per
day copayments the Billed charge or the Preferred or Member rate after you have met any

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Blue Cross and Blue Shield Service Benefit Plan 2000
applicable deductibles For example if you receive four days of inpatient mental condition care at a Member hospital for which your copayments are 1,000 4 x 250 the Billed charge is 900 and
the Member rate is 800 you will be responsible for the Member rate 800 For Non member facilities you will be responsible for the lesser of the sum of your copayments or the Billed charge

If provider waives If a provider routinely waives does not require you to pay your share of the charge for services
your share rendered the Plan is not obligated to pay the full percentage of the amount of the provider's original charge it would otherwise have paid A provider or supplier who routinely waives coinsurance

copayments or deductibles is misstating the actual charge This practice may be in violation of the law The Plan will base its percentage on the fee actually charged For example if the provider

ordinarily charges 100 for a service but routinely waives the 25 coinsurance the actual charge is 75 The Plan will pay 56.25 75 of the actual charge of 75

Lifetime maximums Under High and Standard Options benefits are limited to 100 per person per lifetime for one smoking cessation treatment program see page 30
Under High and Standard Options inpatient care for treatment of alcoholism and drug abuse is limited to one treatment program 28 day maximum per person per lifetime see page 25

When you change options within the Blue Cross and Blue Shield Service Benefit Plan you and any covered family members are entitled to new benefits subject to the deductibles limitations
exclusions and definitions of the new option Benefit amounts accrued under High Option or Standard Option are accumulated in a permanent record regardless of the number of enrollment
changes
Do I have to submit You usually do not have to submit claims to us if you use Preferred providers If you file a claim please send us all of the documents for your claim as soon as possible You must submit claims by
claims December 31 of the year after the year you received the service Either OPM or we can extend this deadline if you show that circumstances beyond your control prevented you from filing on time

Please see Section 6 How to file a claim for specific information you need to know before you file a claim with us

Who provides my In a Fee for Service plan you may choose any covered facility or provider
health care
Covered facilities Covered facility providers include Preferred Facility A facility that has an agreement with a local Blue Cross or Blue Shield Plan to

accept the Plan's Preferred rate for services to Plan members Contact your Local Plan to find out if the facility you are interested in is a Preferred facility

Member Facility A facility that has an agreement with a local Blue Cross or Blue Shield Plan to accept the Plan's Member rate for services to Plan members Contact your Local Plan to find out if
the facility you are interested in is a Member facility
Non Member Facility A facility that is not a Preferred or Member facility

Freestanding Freestanding Ambulatory Facility A freestanding facility which meets the following
ambulatory criteria
facilities 1 Your services are performed in an outpatient setting that is not generally considered an office or clinic for the private practice of a doctor or other professional

2 The facility contains permanent amenities and equipment primarily for the purpose of performing medical surgical and or renal dialysis procedures and

3 Your treatment will be provided by or under the supervision of doctors and or nurses and may include other ancillary professional services performed at the facility

Some examples of ambulatory facilities include freestanding ambulatory medical facilities ambulatory surgical centers freestanding surgi centers and freestanding dialysis centers In
addition we may at our discretion recognize any other like facilities as freestanding ambulatory facilities

Hospitals Hospital An institution or distinct part of an institution that 1 for compensation from its patients and on an inpatient basis is engaged primarily in providing diagnostic and therapeutic
facilities for surgical and medical diagnoses treatment and care of injured and sick persons by or under the supervision of a staff of licensed doctors of medicine M D or licensed doctors of

osteopathy D O 2 continuously provides 24 hour a day professional registered nursing R N services and 3 is not other than incidentally an extended care facility a nursing home
a place for rest an institution for exceptional children the aged drug addicts or alcoholics or a
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Blue Cross and Blue Shield Service Benefit Plan 2000
custodial or domiciliary institution which has as its primary purpose the furnishing of food shelter training or non medical personal services

College infirmaries are considered Non member hospitals In addition we may at our discretion recognize any institution located outside the 50 states and the District of Columbia as
a Non member hospital
Skilled nursing Qualified Skilled Nursing Facility A facility that
facilities 1 specializes in skilled care and meets Medicare's special qualifying criteria and 2 has the staff and equipment to provide skilled nursing care performed by or under the

supervision of licensed nursing personnel or skilled rehabilitation services such as physical therapy performed by or under the supervision of a professional therapist and other related
health services
The term qualified skilled nursing facility does not include any institution that primarily cares for and treats mental diseases

Cancer research Cancer Research Facility A facility that is 1 a National Cooperative Cancer Study Group
facilities institution that is funded by the National Cancer Institute NCI and has been approved by a Cooperative Group as a bone marrow transplant center 2 an NCI designated Cancer Center or

3 an institution that has an NCI funded peer reviewed grant to study allogeneic or autologous bone marrow transplants and blood stem cell transplant support

Others Others as set forth within the benefits description
How facilities See Definitions for an explanation of Preferred rate Member rate Non member rate Average
are paid charge and Billed charge under Covered charges

Covered providers Covered professional providers include Physician Doctors of medicine M D osteopathy D O dental surgery D D S medical

dentistry D M D podiatric medicine D P M and optometry O D when acting within the scope of their licenses are considered physicians

Attending Physician The physician who has responsibility for the care and treatment of the member on an inpatient basis A consulting physician who is an employee of the hospital in
which the member is an inpatient is not the attending physician
The following are considered covered providers when they perform covered services within the scope of their license or certification

Independent Laboratory A laboratory that is licensed under State law or where no licensing requirement exists is approved by the Local Plan
Qualified Clinical Psychologist A psychologist who 1 is licensed or certified in the state where the services are performed 2 has a doctoral degree in psychology or an allied degree if
in the individual state the academic licensing certification requirement for clinical psychologist is met by an allied degree or meets the requirements of the Carrier and 3 has met the clinical
psychological experience requirements of the individual State Licensing Board
Nurse Midwife A person who is certified by the American College of Nurse Midwives or is licensed or certified as a nurse midwife in states requiring licensure or certification

Nurse Practitioner Clinical Specialist A person who 1 has an active R N license in the United States 2 has a baccalaureate or higher degree in nursing and 3 is licensed or certified
as a nurse practitioner or clinical nurse specialist in states requiring licensure or certification

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Blue Cross and Blue Shield Service Benefit Plan 2000
Clinical Social Worker A social worker who 1 has a master's or doctoral degree in social work 2 has at least two years of clinical social work practice and 3 in states requiring
licensure certification or registration is licensed certified or registered as a social worker where the services are rendered

Nursing School Administered Clinic A clinic that is 1 licensed or certified in the state where the services are performed and 2 provides ambulatory care in an outpatient setting
primarily in rural or inner city areas where there is a shortage of physicians Services billed for by these clinics are considered outpatient office services rather than facility charges

Others as set forth within the benefits description
Coverage in Within States designated as medically underserved areas any licensed medical practitioner will be
medically treated as a covered provider for any covered services performed within the scope of that license For 2000 the States designated as medically underserved are Alabama Idaho Kentucky Louisiana
underserved Mississippi Missouri New Mexico North Dakota South Carolina South Dakota Utah and
areas Wyoming

How providers There are four types of Allowable charges the Preferred Provider Allowance PPA which applies
are paid to charges from Preferred professional providers and pharmacies the Participating Provider Allowance PAR which applies to charges from Participating professional providers the Nonparticipating

Provider Allowance NPA which applies to charges from Non participating professional providers and the Average Wholesale Price AWP which applies to charges from

Non preferred pharmacies See Definitions for an explanation of Allowable charges under Covered charges and Preferred Participating and Non participating physicians Most Preferred physicians
accept 100 of the PPA as payment in full see below for exceptions In most cases when you use a Preferred physician you are responsible for your coinsurance after any applicable deductible has
been met and are not responsible for any covered expense in excess of the PPA
Note Providers who contract with more than one Local Plan may be Preferred in one area and Participating in a different area To verify the status of a provider contact the Local Plan serving the

area where services are rendered
Participating physicians usually accept 100 of the Local Plan's PAR as payment in full That means when you use a Participating physician you are usually only responsible for your coinsurance

for covered services after any applicable deductible has been met and are not responsible for any covered expense in excess of the PAR In some Plan areas physicians who were formerly
Participating physicians are now Preferred physicians for the purposes of this Plan
In the following areas there are Preferred physicians but no Participating physicians for the purposes of either option of this Plan

Alabama Kansas Puerto Rico Alaska Mississippi South Carolina
California Blue Nevada Tennessee Shield
Connecticut New Hampshire Vermont Illinois New Jersey Wyoming

New York areas served by the Empire and Rochester
Plans Non participating physicians on the other hand may but are not required to accept the Local Plan's
NPA as payment in full These physicians may bill you up to their charge even after the Local Plan has paid its portion of your bill Members may be held responsible for any amounts over the NPA
in addition to applicable coinsurance amounts copayment amounts amounts applied to the calendar year deductible and noncovered services It is important that you are aware that your out ofpocket
costs may be higher when you use Non participating physicians

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Blue Cross and Blue Shield Service Benefit Plan 2000
In the following areas there are Preferred hospitals but no Member hospitals for the purposes of either option of this Plan
Alabama Nevada Pennsylvania areas Connecticut New Hampshire served by the
Illinois New Jersey Harrisburg Plan Kansas New York areas served by Rhode Island
Maine the Buffalo Empire Vermont Maryland Rochester and Wyoming
Montana Utica Watertown Plans

When this Plan pays In all Local Plan areas other than those described below Preferred physicians will accept 100 PPA
primary or secondary as payment in full and Participating physicians will accept 100 PAR as payment in full for covered services As a result you are only responsible for applicable coinsurance amounts copayment
benefits amounts amounts applied to the calendar year deductible and noncovered services Any balance above the applicable Allowable charge PPA or PAR billed by a Preferred or Participating

physician under either High Option or Standard Option should be brought to the attention of the Local Plan

Exception when this In Arizona if there is secondary coverage not administered by this Plan or other source of
Plan pays primary payment Preferred and Participating physicians are not obligated to accept the PPA or PAR as payment in full

Exceptions when this In Puerto Rico Preferred physicians can collect the difference between the Plan's payment and
Plan pays secondary the physician's charge In Montana Preferred and Participating physicians can collect the difference between the Plan's

payment and the physician's charge
In Pennsylvania and Utah the agreement described above applies only when the Local Plan makes a payment as the secondary payer to other coverage see pages 45 47

In the following areas Preferred and Participating physicians can collect the difference between the Plan's payment and the physician's charge except when this Plan pays secondary to other
Blue Cross and Blue Shield coverage
New York areas served South Carolina by the Rochester Plan Vermont

Rhode Island West Virginia

The above agreement applies only when the primary coverage is administered by the same Local Plan

Areas outside the The Washington DC Plan processes overseas claims see page 40 for instructions on submitting
United States and overseas claims at Preferred levels based on an Overseas Fee Schedule You are responsible for the difference between the Plan's payment and the provider's charge
Puerto Rico

What do I do if I'm First call our customer service department at the telephone number listed on the back of your
in the hospital when Service Benefit Plan identification card If you are new to the FEHB Program we will reimburse
I join this Plan your covered expenses If you are currently in the FEHB Program and are switching to us your former plan will pay for the hospital stay until

You are discharged not merely moved to an alternative care center or
You exhaust the benefits available from your former plan or
The 92 nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized

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Blue Cross and Blue Shield Service Benefit Plan 2000
What if I have a Please contact us if you believe your condition is chronic or disabling If it is you may be able to
serious illness and continue seeing your provider for up to 90 days after you receive notice that we are terminating our
my provider leaves contract with the provider unless the termination is for cause If you are in the second or third trimester of pregnancy you may continue to see your OB GYN until the end of your postpartum
the Plan or this Plan care
leaves the Program You may also be able to continue seeing your provider if your plan drops out of the FEHB Program
and you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic condition or are in the second or third trimester Your new plan will pay for or provide

your care for up to 90 days after you receive notice that your prior plan is leaving the FEHB Program If you are in your second or third trimester your new plan will pay for the OB GYN care
you receive from your current provider until the end of your postpartum care
If you continue seeing your specialist or OB GYN under these conditions your cost will be no more than you would normally pay for the services covered

How do I decide if a
service is Each Local Plan has a Medical Review department that makes these determinations after consulting
experimental or with internal or external experts or nationally recognized guidelines in a particular field or specialty
investigational For more detailed information contact your Local Plan at the telephone number located on the back of your identification card

Experimental or A drug device or biological product is experimental or investigational if the drug device or
investigational biological product cannot be lawfully marketed without approval of the U S Food and Drug Administration FDA and approval for marketing has not been given at the time it is furnished

Approval means all forms of acceptance by the FDA

A medical treatment or procedure or a drug device or biological product is experimental or investigational if 1 reliable evidence shows that it is the subject of ongoing phase I II or III

clinical trials or under study to determine its maximum tolerated dose its toxicity its safety its efficacy or its efficacy as compared with the standard means of treatment or diagnosis or
2 reliable evidence shows that the consensus of opinion among experts regarding the drug device or biological product or medical treatment or procedure is that further studies or clinical trials are
necessary to determine its maximum tolerated dose its toxicity its safety its efficacy or its efficacy as compared with the 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 biological product or medical treatment or procedure or the written informed consent used by the treating facility or by another
facility studying substantially the same drug device or medical treatment or procedure

Section 4 What if we deny your claim or request for
pre authorization

What should I do Before you ask us to reconsider your claim you should first check with your provider or facility to be sure that the claim was filed correctly For instance did the provider use the correct procedure
before filing a code for the services performed surgery laboratory test X ray office visit etc Have your
disputed claim provider indicate any complications of any surgical procedures performed Your provider should also include copies of an operative or procedure report or other documentation that supports your
claim
If we deny your request for pre authorization or won't pay your claim you may ask us to reconsider our decision Your request must

1 Be in writing
2 Refer to specific brochure wording in explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were unable to make a timely request due to reasons beyond

your control
We have 30 days from the date we receive your reconsideration request to

1 Maintain our denial in writing
2 Pay the claim

12 12
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Blue Cross and Blue Shield Service Benefit Plan 2000
3 Approve your request for pre authorization or
4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30 days after we receive the additional information If we do not

receive the requested information within 60 days we will make our decision based on the information we already have

When may I ask OPM You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal
to review a denial OPM will determine if we correctly applied the terms of our contract when we denied your claim or request for service

What if I have a Call us at the telephone number located on the back of your identification card and we will expedite
serious or lifethreatening our review
condition
and you haven't
responded to my
request for preauthorization

What if you have If we expedite your review due to a serious medical condition and deny your claim we will inform
denied my claim for OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's health benefits Contracts Division I at 202 606 0727 between 8 a m and 5 p m Serious or lifethreatening
care and my condition conditions are ones that may cause permanent loss of bodily functions or death if they
is serious or lifethreatening are not treated as soon as possible

Are there other time You must write to OPM and ask them to review our decision within 90 days after we uphold our
limits initial denial or refusal You may also ask OPM to review your claim if 1 We do not answer your request within 30 days In this case OPM must receive your request

within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30 days In this case OPM must receive your request within 120 days of the date we asked you for

additional information
What do I send to Your request must be complete or OPM will return it to you You must send the following
OPM information 1 A statement about why you believe our decision is wrong based on specific benefit provisions

in this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills medical records and explanation of benefits EOB forms

3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to which claim

Who can make the Those who have a legal right to file a disputed claim with OPM are
request 1 Anyone enrolled in the Plan

2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled person's representative They must send a copy of the person's specific written consent with the

review request

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Blue Cross and Blue Shield Service Benefit Plan 2000
Where should I mail Send your request for review to Office of Personnel Management Office of Insurance Programs
my disputed claim to Contracts Division I P O Box 436 Washington D C 20044
OPM

What if OPM upholds OPM's decision is final There are no other administrative appeals If OPM agrees with our
the Plan's denial decision your only recourse is to sue If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third

year after the year in which you received the disputed services or supplies
What laws apply if I Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its
file a lawsuit review on the record that was before OPM when OPM made its decision on your claim You may recover only the amount of benefits in dispute

You or a person acting on your behalf may not sue to recover benefits on a claim for treatment services supplies or drugs covered by us until you have completed the OPM review procedure
described above
Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and
the Privacy Act us to determine if our denial of your claim is correct The information OPM collects during the review process becomes a permanent part of your disputed claims file and is subject to the

provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this information to support the disputed claim decision If you file a lawsuit this information will

become part of the court record

14 14
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Blue Cross and Blue Shield Service Benefit Plan 2000
Section 5 Benefits
Inpatient Hospital Benefits
What is covered The Plan provides coverage for inpatient hospital services as shown below

Precertification The medical necessity of your hospital admission must be precertified for you to receive full Plan benefits Emergency admissions not precertified must be reported within two business days
following the day of admission even if you have been discharged Otherwise the benefits payable will be reduced by 500 See pages 47 48 for details

Waiver This precertification requirement does not apply to persons whose primary coverage is Medicare Part A or another health insurance policy or when the hospital admission is outside the United
States For information on when Medicare is primary see page 43

Room and board The Plan provides coverage at the benefit levels indicated below for services provided by the
and following facilities when furnished and billed as regular inpatient hospital services
Other charges
High Option Standard Option

PPO Preferred You pay nothing for unlimited You pay nothing for unlimited hospitals days days

Member After you pay a 100 per After you pay a 250 per hospitals admission deductible you pay admission deductible you pay
nothing for unlimited days nothing for unlimited days
Non member In the United States and Puerto Rico you pay a 100 per admission hospitals deductible under High Option you pay a 250 per admission
deductible under Standard Option
In addition you pay 30 of the Non member rate see Definitions and any remaining balance after the Plan has made its payment

You pay nothing for facilities outside of the United States and Puerto Rico
Note You should be aware that some Preferred hospitals may have Non preferred providers on staff Following is a list of some of the frequently referred providers about whose Preferred status
you should inquire to help ensure that you receive your maximum benefits Radiologist Pathologist Anesthesiologist and Assistant Surgeon

Room and board Covered services are noted below
Semiprivate accommodations
Intensive care units

Private room A private room is covered only when the patient's isolation is required by law when the Carrier determines that isolation is medically necessary to prevent contagion or in Preferred and Member
hospitals when the hospital only offers private rooms
In noncovered private accommodations and in other noncovered accommodations the Plan pays the hospital's average daily rate for semiprivate accommodations which is determined by the Local

Plan Other hospital services are paid as shown above
Other hospital Operating recovery and other treatment rooms
charges Drugs and medical supplies

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider 15 When no PPO provider is available non PPO benefits apply 15
15 Page 16 17
Blue Cross and Blue Shield Service Benefit Plan 2000
X rays Magnetic Resonance Imagings MRIs laboratory and pathological services and machine diagnostic tests
Dressings splints plaster casts
Anesthetics and anesthesia service
Administration of blood and blood plasma see page 29 for coverage of blood and blood products

Pre admission testing recognized as part of the hospital admissions procedures
Limited benefits

Hospitalization for The Plan pays for room and board and other hospital services for hospitalization in connection with
dental work dental procedures only when a nondental physical impairment exists that makes hospitalization necessary to safeguard the health of the patient

Chemotherapy Chemotherapy and or radiation therapy when supported by allogeneic or autologous bone marrow
radiation therapy transplants or blood stem cell transplant support is only covered for specific diagnoses see Organ tissue transplants and donor expenses under Surgical Benefits on pages 17 20

Related benefits
Outpatient hospital See pages 26 27 for outpatient hospital care benefits and outpatient surgery facility care benefits
benefits

Surgical benefits See pages 17 20 for surgical benefits when provided or ordered and billed by a physician
Other charges See Other Medical Benefits for coverage of blood drugs and ambulance transport services
Inhospital The Plan provides coverage at the benefit levels indicated below for the following nonsurgical
physician care services provided or ordered and billed by a physician High Option Standard Option

PPO Preferred You pay 5 PPA After you pay the 200 calendar physicians year deductible you pay 10
PPA
Participating You pay 20 PAR After you pay the 200 calendar physicians year deductible you pay 25

PAR
Nonparticipating You pay 20 NPA You are After you pay the 200 calendar also responsible for the year deductible you pay 25

physicians difference between the Plan's NPA You are also responsible payment and the physician's for the difference between the
actual charge Plan's payment and the physician's actual charge

See Definitions for an explanation of Preferred Participating and Non participating physicians and PPA PAR and NPA under Covered charges
Medical care by the attending physician on days covered by Inpatient Hospital Benefits
Intensive physician care by the attending physician for treatment of a condition other than that for which surgical or maternity care is required

Consultations when requested by the attending physician not including routine radiological and staff consultations required by hospital rules and regulations
Concurrent care see Definitions
Physical therapy when provided by a physician other than the attending physician

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider
16 When no PPO provider is available non PPO benefits apply 16
16 Page 17 18
Blue Cross and Blue Shield Service Benefit Plan 2000
What is not Room and board and inhospital physician care when in the Carrier's judgment a hospital admission or portion of an admission is one of the following types
covered Custodial care see Definitions

Convalescent care or a rest cure
Domiciliary care provided because care in the home is not available or is unsuitable
Inpatient private duty nursing
Not medically necessary i e for services that did not require the acute hospital inpatient overnight setting but could have been provided in a physician's office the outpatient

department of a hospital or some other setting without adversely affecting the patient's condition or the quality of medical care rendered Some examples are

admissions for or consisting primarily of observation and or evaluation that could have been provided safely and adequately in some other setting e g physician's office
admissions primarily for diagnostic studies X rays Magnetic Resonance Imagings MRIs laboratory and pathological services and machine diagnostic tests that could have been
provided safely and adequately in some other setting e g outpatient department of a hospital or physician's office

If a hospital admission is determined to be one of the types listed above the Plan will pay benefits for services or supplies other than room and board and inhospital physician care at the level at which
they would have been covered if provided in some other setting

Surgical Benefits
What is covered The Plan provides coverage at the benefit levels indicated below except as noted for the following services provided or ordered and billed by a physician
High Option Standard Option
PPO Preferred You pay 5 PPA After you pay the 200 calendar physicians year deductible you pay 10

PPA
Participating You pay 20 PAR After you pay the 200 calendar physicians year deductible you pay 25

PAR
Nonparticipating You pay 20 NPA You are After you pay the 200 calendar also responsible for the year deductible you pay 25
physicians difference between the Plan's NPA You are also responsible payment and the physician's for the difference between the
actual charge Plan's payment and the physician's actual charge

See Definitions for an explanation of Preferred Participating and Non participating physicians and PPA PAR and NPA under Covered charges

Surgical services Operative or cutting procedures including treatment of fractures and dislocations surgical sterilization and normal pre and post operative care by the operating physician
Diagnostic procedures such as endoscopies and biopsies
Treatment of burns
Surgical correction of congenital anomalies see Definitions

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider 17 When no PPO provider is available non PPO benefits apply 17
17 Page 18 19
Blue Cross and Blue Shield Service Benefit Plan 2000
Extraction or reinfusion of bone marrow blood stem cells or cord blood as a source of stem cells as part of an allogeneic or autologous bone marrow transplant or blood stem cell transplant
support procedure including marrow harvesting in anticipation of a covered autologous bone marrow transplant for patients diagnosed at the time of harvesting with one of the conditions
listed on pages 18 19 The collection processing storage and distribution of cord blood must be performed by a cord blood bank approved by the FDA Expenses for storage of harvested
bone marrow blood stem cells or cord blood as a source of stem cells are not covered unless the covered transplant has already been scheduled

When unusual circumstances require removal of casts or sutures by a physician other than the one who applied them the Local Plan may determine that a separate allowance is payable
Surgical correction of amblyopia and strabismus
Multiple surgical When multiple or bilateral surgical procedures that add time or complexity to patient care are
procedures performed during the same operative session the Plan pays these multiple bilateral or incidental surgical combined procedures on the basis of the Allowable charge that is determined by the Local

Plan The Plan determines which procedure is primary and which procedures are secondary tertiary etc and provides a reduced allowance for the non primary procedures

Assistant surgeon Surgical assistance by a physician if required by the complexity of the surgical procedure
inpatient outpatient

Anesthesia Anesthesia service including acupuncture when requested by the attending physician and
inpatient outpatient performed by a certified registered nurse anesthetist CRNA or a physician other than the operating physician or the assistant for covered surgical services CRNAs are reimbursed at the payment

levels indicated above for Participating and Non participating physicians

Organ tissue
transplants and donor
expenses

What is covered The following human organ tissue transplant procedures
Allogeneic bone marrow transplant and allogeneic cord blood stem cell transplant from related or unrelated donors for 1 Advanced neuroblastoma 2 Infantile malignant osteopetrosis

3 Severe combined immunodeficiency 4 Wiskott Aldrich syndrome 5 Mucopolysaccharidosis e g Hunter Hurler's Sanfilippo Maroteaux Lamy variants
6 Mucolipidosis e g Gaucher's disease metachromatic leukodystrophy adrenoleukodystrophy 7 Severe or very severe aplastic anemia 8 Thalassemia major
homozygous beta thalassemia and 9 Sickle cell anemia
Allogeneic bone marrow transplant allogeneic cord blood stem cell transplant from related or unrelated donors and allogeneic peripheral blood stem cell transplant for 1 Acute lymphocytic

or non lymphocytic i e myelogenous leukemia 2 Advanced Hodgkin's lymphoma 3 Advanced non Hodgkin's lymphoma 4 Chronic myelogenous leukemia and 5 Advanced
forms of myelodysplastic syndromes
Autologous bone marrow transplant and autologous peripheral blood stem cell transplant collectively referred to as autologous stem cell support for 1 Acute lymphocytic or

nonlymphocytic i e myelogenous leukemia 2 Advanced Hodgkin's lymphoma 3 Advanced non Hodgkin's lymphoma 4 Advanced neuroblastoma 5 Testicular Mediastinal
Retroperitoneal and Ovarian germ cell tumors and 6 Multiple myeloma
Allogeneic bone marrow transplant syngeneic bone marrow transplant and allogeneic peripheral blood stem cell transplant for 1 Multiple myeloma 2 Chronic lymphocytic

leukemia and 3 early stage indolent or non advanced small cell lymphocytic lymphoma and autologous bone marrow transplant and autologous peripheral blood stem cell transplant
collectively referred to as autologous stem cell support for 1 Breast cancer 2 Epithelial ovarian cancer 3 Chronic myelogenous leukemia 4 Chronic lymphocytic leukemia and 5
early stage indolent or non advanced small cell lymphocytic lymphoma only when performed as part of a clinical trial that meets the requirements noted in the Limitations below and is
conducted at a Cancer Research Facility see page 9

18 The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider When no PPO provider is available non PPO benefits apply 18
18 Page 19 20
Blue Cross and Blue Shield Service Benefit Plan 2000
In the event no non randomized clinical trials meeting the requirements set forth below are available at Cancer Research Facilities for a member eligible for such clinical trials the Plan
will make arrangements for the transplant to be provided at another Plan designated transplant facility

Related services or supplies provided to the recipient are covered including chemotherapy and or radiation therapy when supported by allogeneic or autologous bone marrow transplants or blood
stem cell transplant support and drugs or medications administered to stimulate or mobilize stem cells for the transplant procedures described above

Single or double lung transplants for the following end stage pulmonary diseases 1 Pulmonary fibrosis 2 Primary pulmonary hypertension and 3 Emphysema
Double lung transplant for end stage cystic fibrosis
Cornea Heart Heart lung Small bowel Kidney Liver Pancreas

Related medical and hospital expenses of the donor are covered
Limitations Prior approval by the Local Plan of the procedure and the facility is required for bone marrow
cord blood stem cell and peripheral blood stem cell transplant support procedures heart heartlung liver lung pancreas and small bowel transplants see page 48

For the bone marrow transplant procedures and related services or supplies covered only through clinical trials
1 Prior approval by the Carrier is required see page 48
2 The clinical trial must be reviewed and approved by the Institutional Review Board of the Cancer Research Facility where the procedure is to be delivered and

3 The patient must be properly and lawfully registered in the clinical trial meeting all the eligibility requirements of the trial

What is not covered Services or supplies for or related to artificial or human organ tissue transplants for any diagnosis not specifically listed as covered Related services or supplies for noncovered procedures including
chemotherapy and or radiation therapy when supported by allogeneic or autologous bone marrow transplants cord blood stem cell transplants from related or unrelated donors or peripheral blood

stem cell transplant support drugs or medications administered to stimulate or mobilize stem cells for transplant and all other services or supplies which would not be medically necessary or
appropriate but for the noncovered procedure
Oral and Limited to the following surgical procedures
maxillofacial Excision of tumors and cysts of the jaws cheeks lips tongue roof and floor of mouth when
surgery pathological examination is required Surgery needed to correct accidental injuries see Definitions to jaws cheeks lips tongue roof

and floor of mouth
Excision of exostoses of jaws and hard palate
External incision and drainage of cellulitis
Incision and surgical treatment of accessory sinuses salivary glands or ducts
Reduction of dislocations and excision of temporomandibular joints
Removal of impacted teeth

Mastectomy surgery Women who undergo mastectomies may at their option have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure A patient and her
attending physician may decide whether to have breast reconstruction surgery following a mastectomy and whether surgery on the other breast is needed to produce a symmetrical appearance

see page 20

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider 19 When no PPO provider is available non PPO benefits apply 19
19 Page 20 21
Blue Cross and Blue Shield Service Benefit Plan 2000
Reconstructive Benefits will be provided for
surgery Treatment to restore the mouth to a pre cancer state

Breast reconstruction surgery following a mastectomy including surgery to produce a symmetrical appearance on the other breast Benefits will be provided for all stages of breast

reconstruction following a mastectomy including treatment of any physical complications including lymphedemas and for breast prostheses including surgical bras and replacements

Related benefits
Outpatient surgery Outpatient surgical services billed for by a facility are covered under Other Medical Benefits See
facility care benefits page 27

What is not covered Cosmetic surgery see Definitions unless required for a congenital anomaly or to restore or correct a part of the body which has been altered as a result of accidental injury disease or
surgery
Radial keratotomy and other refractive surgeries
Services for or related to reversal of surgical sterilization

20 The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider When no PPO provider is available non PPO benefits apply 20
20 Page 21 22
Blue Cross and Blue Shield Service Benefit Plan 2000
Maternity Benefits

What is covered The Plan provides coverage at the benefit levels indicated below for services provided by the following facilities when furnished and billed as regular inpatient hospital services The mother at her option may remain in the hospital up to 48 hours after a vaginal delivery and 96 hours after a
cesarean delivery Inpatient stays will be extended if medically necessary

Inpatient
hospital

Precertification Precertification is not required for maternity admissions for routine deliveries However if your medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a
cesarean section your physician or the hospital must contact the Local Plan for certification of additional days The Plan will not pay for charges incurred on any extra days that are not medically
necessary See pages 47 48 for details
High Option Standard Option
PPO Preferred You pay nothing for unlimited You pay nothing for unlimited hospitals days days

Member After you pay a 100 per After you pay a 250 per hospitals admission deductible you pay admission deductible you pay
nothing for unlimited days nothing for unlimited days
Non member In the United States and Puerto Rico you pay a 100 per admission hospitals deductible under High Option you pay a 250 per admission
deductible under Standard Option
In addition you pay 30 of the Non member rate see Definitions and any remaining balance after the Plan has made it's payment

You pay nothing for facilities outside of the United States and Puerto Rico

Covered services are noted below
Room and board Room and board and other hospital services See Inpatient Hospital Benefits for a description of all covered services and payment levels for Non member hospitals

Private room A private room is covered only when the patient's isolation is required by law when the Carrier determines that isolation is medically necessary to prevent contagion or in Preferred and Member
hospitals when the hospital only offers private rooms
In noncovered private accommodations and in other noncovered accommodations the Plan pays the hospital's average daily rate for semiprivate accommodations which is determined by the Local

Plan Other hospital services are paid as shown above
Bassinet and nursery Hospital bassinet or nursery charges for days in which both the mother and newborn are confined in the hospital are considered as expenses of the mother and not expenses of the child When a

newborn requires definitive treatment including incubation charges by reason of prematurity or evaluation for medical or surgical reasons during or after the mother's confinement the newborn is

considered a patient in his or her own right and a separate per admission deductible if applicable applies Expenses of the newborn including circumcision are eligible for benefits only if the child
is covered by a Self and Family enrollment See page 48 for information on requesting additional days for a covered newborn confined beyond the mother's discharge date

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider 21 When no PPO provider is available non PPO benefits apply 21
21 Page 22 23
Blue Cross and Blue Shield Service Benefit Plan 2000
Other charges Operating recovery and other treatment rooms
Drugs and medical supplies
Other covered ancillary services

Outpatient care Outpatient hospital care for delivery including care in freestanding ambulatory facilities including birthing centers is covered as described under Other Medical Benefits Outpatient surgery Facility
care benefits see page 27
Note When you use Preferred facilities benefits for obstetrical care including prenatal testing are provided in full not subject to the calendar year deductible or copayment

Professional care The Plan provides coverage at the benefit levels indicated below for services provided or ordered and billed by a physician or nurse midwife
High Option Standard Option
PPO Preferred You pay nothing You pay nothing physicians

Participating You pay 20 PAR After you pay the 200 calendar physicians Nurse year deductible you pay 25
midwives PAR
Non participating You pay 20 NPA You are After you pay the 200 calendar physicians Nurse also responsible for the year deductible you pay 25

midwives difference between the Plan's NPA You are also responsible payment and the physician's for the difference between the
actual charge Plan's payment and the physician's actual charge

See Definitions for an explanation of Preferred Participating and Non participating physicians and PAR and NPA under Covered charges

Obstetrical care Physician care for pregnancy including related conditions and resulting childbirth or miscarriage
Services of a licensed or certified nurse midwife for pre and post partum care and delivery
Anesthesia services services of a nurse anesthetist and surgical assistance as described under Surgical Benefits

Related benefits
Contraceptive Intrauterine devices IUDs Norplant Depo Provera diaphragms and oral contraceptives
devices obtained from a physician are covered at the levels indicated on page 17 when obtained from a facility they are covered at Other Medical Benefit levels see page 27
and drugs IUDs Norplant Depo Provera diaphragms and oral contraceptives dispensed by a retail pharmacy are covered as prescription drugs see page 34

Oral contraceptives are also covered under the Mail Service Prescription Drug Program see page 34

Diagnosis and Diagnosis and treatment of infertility are covered at the benefit levels indicated on page 17 related
treatment of prescription drugs are covered under Prescription Drug Benefits see pages 34 35 see exclusion below for Assisted Reproductive Technology ART procedures
infertility

Prenatal testing Prenatal testing is covered at the benefit levels shown above and on page 27

22 The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider When no PPO provider is available non PPO benefits apply 22
22 Page 23 24
Blue Cross and Blue Shield Service Benefit Plan 2000
Voluntary Sterilization procedures see page 17 for benefits for surgical sterilization
sterilization

Well child care Well child care is covered under Additional Benefits see page 31
For whom Benefits are payable under Self Only enrollments and for family members under Self and Family enrollments

What is not covered Assisted Reproductive Technology ART procedures such as artificial insemination in vitro fertilization embryo transfer and GIFT as well as services and supplies related to ART
procedures including sperm banking
Reversal of voluntary sterilization
Contraceptive devices except as specifically described above

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider 23 When no PPO provider is available non PPO benefits apply 23
23 Page 24 25
Blue Cross and Blue Shield Service Benefit Plan 2000
Mental Conditions Substance Abuse Benefits
What is covered The Plan provides coverage at the benefit levels indicated below for services provided by the following facilities and professionals when furnished and billed as regular inpatient hospital
services

Mental conditions Note Please check with your Local Plan and or PPO directory for listings of Preferred facilities and contracted professional providers

Inpatient care
Precertification The medical necessity of your admission to a hospital or other covered facility must be precertified for you to receive full Plan benefits Emergency admissions must be reported within two business
days following the day of admission even if you have been discharged Otherwise the benefits payable will be reduced by 500 See pages 47 48 for details

Hospital care High Option Standard Option
PPO Preferred You pay a 75 per day You pay a 150 per day hospitals copayment for up to 120 days copayment for up to 100 days

you pay all charges thereafter you pay all charges thereafter
Member You pay a 150 per day You pay a 250 per day hospitals copayment for up to 120 days copayment for up to 100 days

you pay all charges thereafter you pay all charges thereafter
Non member You pay a 300 per day You pay a 400 per day hospitals copayment for up to 120 days copayment for up to 100 days
you pay all charges thereafter you pay all charges thereafter In addition you pay the In addition you pay the
difference between the Plan's difference between the Plan's payment and the provider's payment and the provider's
actual charge actual charge
After you pay the per day copayments the Plan pays the remainder of the Preferred rate Member rate or Non member rate in excess of the sum of your copayments In Preferred and Member
hospitals in some instances when the Preferred or Member rate or the Billed charge is less than the sum of your copayments you will be responsible only for the lowest amount In Non member
hospitals in some instances the Average charge may be less than the sum of your copayments
See the definition of Covered charges for an explanation of Preferred rate Member rate Nonmember rate Billed charge and Average charge See also the discussion of copayments on pages 78

Covered services include room and board and other hospital services see Inpatient Hospital Benefits for a description of all covered services
Inpatient visits The Plan provides coverage at the benefit levels indicated below for inpatient mental conditions and substance abuse professional care rendered by Participating and Non participating providers
High Option Standard Option
After you pay the 150 calendar year After you pay the 200 calendar year deductible you pay 20 of the deductible you pay 40 of the

Allowable charge see Definitions Allowable charge see Definitions

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider
24 When no PPO provider is available non PPO benefits apply 24
24 Page 25 26
Blue Cross and Blue Shield Service Benefit Plan 2000
Outpatient The Plan pays all covered outpatient care including related services and supplies such as
care psychological testing for the treatment of a mental condition including substance abuse as follows
Facility care High Option Standard Option

After you pay the 150 calendar After you pay the 200 calendar year deductible you pay the year deductible you pay the

following copayments following copayments
PPO Preferred You pay 10 You pay 25 facilities

Member You pay 50 You pay 100 facilities
Non member You pay 100 You pay 150 facilities

These copayments will be applied per facility per day not per service After meeting the deductibles you will be responsible for the lesser of the stated copayment or the Billed charge s If
Preferred or Member facilities are available and utilized you will be responsible for the lesser of the stated copayments the Billed charge s or the Preferred or Member rate at the time your claim is
processed
Professional care The Plan provides coverage at the benefit levels described below for outpatient mental conditions and substance abuse professional care rendered by Participating and Non participating providers

High Option Standard Option
After you pay the 150 calendar year After you pay the 200 calendar year deductible you pay 30 of the deductible you pay 40 of the

Allowable charge see Definitions Allowable charge see Definitions

Therapy Outpatient visits are available up to 50 visits under High Option and 25 visits under Standard Option per person per calendar year for

Individual or group therapy or combination of individual and group therapy up to two hours per day including collateral visits with members of the patient's immediate family provided by
a physician qualified clinical psychologist psychiatric nurse or clinical social worker
Day night hospital services sometimes called partial hospitalization

The number of visits for which you receive reimbursement will be reduced if these services are used to meet part or all of your calendar year deductible

Substance abuse
Inpatient care The Plan provides benefits for the inpatient treatment of alcoholism and drug abuse at the levels indicated on the previous page for hospital care and inpatient visits for mental conditions care

Treatment is also payable in a freestanding alcoholism facility approved by the Local Plan

Lifetime maximum Inpatient care for the treatment of alcoholism and drug abuse is limited to one treatment program 28 day maximum per lifetime under High and Standard Options

Outpatient care The Plan provides benefits for outpatient facility and professional care for the treatment of substance abuse at the benefit levels indicated above Outpatient visits accrue toward the visit limits described
above

What is not covered Marital family educational or other counseling or training services Services rendered or billed by a school or halfway house or a member of its staff
Psychoanalysis or psychotherapy credited toward earning a degree or furtherance of education or training regardless of diagnosis or symptoms that may be present

Services and supplies that are not medically necessary see Definitions and General Exclusions

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider 25 When no PPO provider is available non PPO benefits apply 25
25 Page 26 27
Blue Cross and Blue Shield Service Benefit Plan 2000
Other Medical Benefits

What is covered Except as noted after any applicable deductibles and copayments have been met the Plan pays the following
Outpatient High Option Standard Option
facility care After you pay the 150 calendar After you pay the 200 calendar year deductible you pay the year deductible you pay the

following copayments following copayments
PPO Preferred You pay 10 You pay 25 facilities

Member You pay 50 You pay 100 facilities
Non member You pay 100 You pay 150 facilities

These copayments will be applied per facility per day not per service After meeting the deductible you will be responsible for the lesser of the stated copayments or the Billed charge s If Preferred
or Member facilities are available and utilized you will be responsible for the lesser of the stated copayments the Billed charge s or the Preferred or Member rate at the time your claim is
processed
Covered services 1 when furnished by the hospital outpatient department ordered by a physician and billed by a hospital or 2 for renal dialysis when furnished and billed by a freestanding

ambulatory facility see Facilities and Other Providers are as follows
Diagnostic X rays Magnetic Resonance Imagings MRIs laboratory and pathological services and machine
services diagnostic tests Certain diagnostic cancer tests are covered differently when provided by a Preferred facility see page 31

Preventive In Member and Non member facilities each cervical cancer screening mammogram for breast
services cancer screening fecal occult blood test for colorectal cancer screening sigmoidoscopy for colorectal cancer screening PSA Prostate Specific Antigen test for prostate cancer screening

tetanus diphtheria Td booster and immunization for influenza pneumonia and Lyme disease is paid as described above See page 28 for the screening schedules related to these tests and

immunizations for Member and Non member facilities and for Participating and Non participating providers These services are covered differently when you use Preferred providers see page 31

Other Radiation therapy chemotherapy and renal dialysis chemotherapy and or radiation therapy
outpatient when supported by allogeneic or autologous bone marrow transplants or blood stem cell
services transplant support is covered only for those covered conditions as described under Organ tissue transplants and donor expenses under Surgical Benefits on pages 18 19

Physical occupational and speech therapy for visit limitations see page 30 Allergy tests surveys and injections blood as described under Miscellaneous services on

page 29 and prescription drugs billed for by the facility
Hepatitis immunizations for patients with increased risk or family history Hospital services in connection with dental procedures only when a nondental physical

impairment exists that makes hospitalization necessary to safeguard the health of the patient
Pharmacotherapy see pages 34 35 for coverage for prescription drugs

26 The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider When no PPO provider is available non PPO benefits apply 26
26 Page 27 28
Blue Cross and Blue Shield Service Benefit Plan 2000
Outpatient
surgery

Facility The Plan provides coverage at the benefit levels indicated below not subject to the calendar year
care deductible for the outpatient surgical services listed below when billed for by a facility
benefits High Option Standard Option

You pay nothing but the You pay nothing but the following copayments following copayments

PPO Preferred You pay 10 You pay 25 facilities
Member You pay 50 You pay 100 facilities
Non member You pay 100 You pay 150 facilities
These copayments will be applied per facility per day not per service You will be responsible for the lesser of the stated copayments or the Billed charge s If Preferred or Member facilities are
available and utilized you will be responsible for the lesser of the stated copayments the Billed charge s or the Preferred or Member rate at the time your claim is processed

Overseas care You pay nothing for outpatient surgical services at hospitals located outside the United States or Puerto Rico
Covered facility billed services are noted below
Surgical services and related other hospital services
Related X rays Magnetic Resonance Imagings MRIs laboratory and pathological services and machine diagnostic tests performed within one business day of the covered surgical

services Presurgical testing performed more than one business day prior to the surgery is covered as described on page 26 under Outpatient Facility Care Diagnostic services

Facility supplies for hemophilia home care
Physician care Except as noted the Plan provides coverage at the benefit levels indicated below for services provided or ordered and billed by a physician

High Option Standard Option
PPO Preferred After you pay the 150 calendar After you pay the 200 calendar physicians year deductible you pay 5 PPA year deductible you pay 10

PPA
Participating After you pay the 150 calendar After you pay the 200 calendar physicians year deductible you pay 20 year deductible you pay 25

PAR PAR
Non participating After you pay the 150 calendar After you pay the 200 calendar physicians year deductible you pay 20 year deductible you pay 25

NPA You are also responsible NPA You are also responsible for the difference between the for the difference between the
Plan's payment and the Plan's payment and the physician's actual charge physician's actual charge

See Definitions for an explanation of Preferred Participating and Non participating physicians and PPA PAR and NPA under Covered charges

Home and When you use Preferred physicians home and office visits physicians outpatient consultations and
office visits second surgical opinions are paid in full under High and Standard Options after a 12 copayment for each outpatient office visit charge These services are paid as described above when rendered by

Participating and Non participating physicians

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider 27 When no PPO provider is available non PPO benefits apply 27
27 Page 28 29
Blue Cross and Blue Shield Service Benefit Plan 2000
Diagnostic X rays Magnetic Resonance Imagings MRIs laboratory and pathological services and
services machine diagnostic tests including mammograms and Pap smears Certain diagnostic cancer tests are covered differently when provided by a Preferred provider see page 31

Laboratory and pathological services billed by an independent laboratory
Preventive The following routine screening procedures are paid as described above when performed by
services Participating and Non participating providers These services are covered differently when you use Preferred providers and the visit charge associated with these services is covered only with

Preferred providers see Additional Benefits page 31
The following schedules are applicable for Member and Non member facilities and Participating and Non participating providers

Breast Mammograms are covered for females age 35 and older as follows
cancer From age 35 through 39 one mammogram screening during this five year period
screening From age 40 through 64 one mammogram screening every calendar year

At age 65 or over one mammogram screening every two consecutive calendar years

Cervical cancer One Pap smear for females of any age every calendar year
screening

Colorectal cancer One fecal occult blood test for members age 40 and older every calendar year
screening One sigmoidoscopy for members age 50 and older every five years

Prostate cancer One PSA Prostate Specific Antigen test for males age 40 and older every calendar year
screening

Immunizations For influenza and pneumonia once every calendar year
Tetanus diphtheria Td booster once every ten calendar years
Lyme disease vaccine

Other Radiation therapy chemotherapy and renal dialysis chemotherapy and or radiation therapy
outpatient when supported by allogeneic or autologous bone marrow transplants or blood stem cell
services transplant support is covered only for those covered conditions as described under Organ tissue transplants and donor expenses under Surgical Benefits on pages 17 20

Physical occupational and speech therapy for visit limitations see page 30
Allergy tests surveys and injections blood as described on page 29 and prescription drugs
Hepatitis immunizations for patients with increased risk or family history
Under High Option physician home visits when receiving covered home health care see page 32

Covered services provided by a nurse midwife acting within the scope of licensure
Pharmacotherapy see pages 34 35 for coverage for prescription drugs

Other services Except as noted benefits for the following services are paid as follows
High Option Standard Option

After you pay the 150 calendar year After you pay the 200 calendar year deductible you pay 20 of the deductible you pay 25 of the

Allowable charge see Definitions Allowable charge see Definitions
Note Preferred and Participating providers may not be available for the following services in your area When they are available and utilized the Plan pays benefits as shown under Physician care
on page 27

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider
28 When no PPO provider is available non PPO benefits apply 28
28 Page 29 30
Blue Cross and Blue Shield Service Benefit Plan 2000
Ambulance Professional ambulance transport services
associated with covered hospital inpatient care
related to and within 72 hours after an accidental injury or medical emergency or
during covered home health care

Dental care for Services supplies or appliances for dental care to sound natural teeth see Definitions required as a
accidental injury result of and directly related to an accidental injury see Definitions

Durable medical Rental by the member or purchase at the Carrier's option if it will be less expensive of durable
equipment medical equipment such as respirators and home dialysis equipment including replacement repair and adjustment of purchased equipment

Wheelchairs hospital beds crutches and other items determined by the Carrier to be durable medical equipment

Home nursing Care by a registered nurse R N or licensed practical nurse L P N when the care is ordered by a
care physician Home nursing care is available for two 2 hours per day up to 50 visits per calendar year under High Option and 25 visits per calendar year under Standard Option The number of visits

for which you receive reimbursement will be reduced if these services are used to meet part or all of your calendar year deductible

Miscellaneous Allergy tests surveys and injections
services and Blood and blood plasma except when donated or replaced and blood plasma expanders
supplies Neurological testing when rendered and billed by a qualified clinical psychologist

One set of eyeglasses or contact lenses or one replacement to an existing prescription required as a result of and directly related to a single instance of intra ocular surgery or a single ocular

injury This benefit also applies when in situations as described above the condition can be corrected by surgery but surgery is precluded i e cannot be performed because of age or
medical complications and lenses are prescribed in lieu of surgery
Ostomy and catheter supplies
Oxygen regardless of the provider
Medical foods for children with inborn errors of amino acid metabolism
Prescription drugs not billed by a retail pharmacy excludes those drugs obtained through the Mail Service Prescription Drug Program

Home infusion therapy prescription drugs medical supplies durable medical equipment DME and home nursing visits subject to the calendar year visit limitations described above
under Home nursing care
Nonsurgical treatment for amblyopia and strabismus for children from birth through age 12
Functional foot orthotics when medically necessary and prescribed by a physician

Rigid devices attached to the foot or a brace or placed in a shoe
Acupuncture as a modality of physical therapy and for pain management when rendered and billed by a physician or licensed physical therapist

Orthopedic braces and prosthetic appliances such as artificial legs and pacemakers including replacement repair and adjustment
Diabetic education when billed by a covered provider

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider 29 When no PPO provider is available non PPO benefits apply 29
29 Page 30 31
Blue Cross and Blue Shield Service Benefit Plan 2000
Physical Physical occupational and speech therapy when rendered by a physical occupational or speech
occupational therapist who is licensed or meets the requirements of the Carrier by a physician rendered on an
and speech outpatient basis or by an outpatient facility When billed by a skilled nursing facility nursing home
therapy or extended care facility benefits will be paid as shown on page 27 for professional care according to the contracting status of the professional provider that actually performs the therapy The

following limits apply to outpatient care

Physical therapy 75 visits under High Option and 50 visits under Standard Option per person per calendar year

Occupational therapy speech therapy or a combination of both 25 visits under High and Standard Options per person per calendar year
The number of visits for which you receive reimbursement will be reduced if these services are used to meet part or all of your calendar year deductible

See page 16 for physical occupational and speech therapy provided by a physician on an inpatient basis See pages 26 28 for payment levels for outpatient physical occupational and speech therapy
provided by a physician or outpatient facility
Limited benefits Smoking cessation After satisfaction of the calendar year deductible under High and Standard Options the Plan will

benefit pay 100 of Billed charges up to a maximum payment of 100 for enrollment in one smoking cessation program per member per lifetime Services may be rendered by any covered provider or
by a smoking cessation clinic
See pages 34 35 Prescription Drug Benefits for coverage of smoking cessation drugs

What is not covered Exercise and bathroom equipment Lifts such as seat chair or van lifts
Air conditioners humidifiers dehumidifiers and purifiers Shoes and over the counter orthotics

Wigs Breast pumps
Implanted bone conduction hearing aids Computer story boards or light talkers for communication impaired individuals
Maintenance or palliative physical occupational or speech therapy for a chronic disease or condition which does not require the technical proficiency or the skill and training of a
physician or qualified physical occupational or speech therapist except during acute exacerbations of the disease or condition

Home nursing care when
1 Requested by or for the convenience of the patient or the patient's family or 2 It consists primarily of bathing feeding exercising homemaking moving the patient

giving medication or acting as a companion or sitter

30 The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider When no PPO provider is available non PPO benefits apply 30
30 Page 31 32
Blue Cross and Blue Shield Service Benefit Plan 2000
Additional Benefits
Preventive services The Plan provides coverage for each home and office visit for a routine physical examination at the benefit levels indicated below when provided by a Preferred physician or Preferred facility
provided by After you pay a 12 copayment you After you pay a 12 copayment you
Preferred providers pay nothing under High Option pay nothing under Standard Option

Routine physical Home and office visits for routine screening examination consisting of a history and risk
examination assessment chest X ray electrocardiogram EKG urinalysis basic metabolic or comprehensive metabolic panel test and complete blood count CBC are covered for members as follows

Through age 64 once every three consecutive calendar years
At age 65 or over once every calendar year

This benefit does not apply to children eligible for Well Child Care benefits
Additionally the preventive screening tests and immunizations noted below are paid in full when provided by a Preferred physician or a Preferred facility on an outpatient basis subject to the

schedules indicated If these services are rendered by a Preferred physician separately from the routine physical examination you will be responsible for the 12 copayment for each associated
office visit
Coronary artery Cholesterol tests are covered for members as follows
disease screening Through age 64 once every three consecutive calendar years
At age 65 or over once every calendar year

This benefit does not apply to children eligible for Well Child Care benefits
Preventive screening cholesterol tests are only covered and paid in full when provided by Preferred providers or any independent laboratory

Immunizations For influenza and pneumonia once every calendar year Tetanus diphtheria Td booster once every ten calendar years
Lyme disease vaccine
See pages 26 28 Other Medical Benefits for benefits for these immunizations provided by Member and Non member facilities and Participating and Non participating providers The visit charge

associated with these services is covered only with Preferred facilities or Preferred providers
Cancer tests The following diagnostic and screening cancer tests are paid in full when provided by a Preferred
diagnostic screening facility or a Preferred professional provider on an outpatient basis You are responsible for the 12 copay for each associated office visit
provided by Mammogram
Preferred providers Pap smear Fecal occult blood test

Sigmoidoscopy
PSA Prostate Specific Antigen test

See pages 26 28 Other Medical Benefits for payment levels and applicable schedules for these diagnostic and preventive services provided by Member and Non member facilities and Participating

and Non participating physicians The visit charge associated with these services is covered only with Preferred facilities or Preferred providers

Well child care For children up to age 22 you pay nothing under High and Standard Options for Covered charges for the following covered routine services for well child care
All healthy newborn inpatient physician visits including routine screening inpatient or outpatient

Routine physical examinations laboratory tests immunizations and related office visits including those for children living traveling or adopted from outside the United States as
recommended by the American Academy of Pediatrics

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider When no PPO provider is available non PPO benefits apply
31 31
31 Page 32 33
Blue Cross and Blue Shield Service Benefit Plan 2000
Accidental injury You pay nothing under High and Standard Options for Covered charges for the following covered services and supplies in connection with and within 72 hours after accidental injury see
outpatient care Definitions
Other hospital services in Preferred Member and Non member hospitals including related X rays Magnetic Resonance Imagings MRIs laboratory and pathological services and

machine diagnostic tests
Physician services in the office or hospital outpatient department including X rays Magnetic Resonance Imagings MRIs laboratory and pathological services and machine diagnostic tests

See Definitions for an explanation of Preferred Participating and Non participating physicians and Covered charges

Related benefits The following related services are covered under Other Medical Benefits see pages 26 30
Services related to accidental injury rendered more than 72 hours after the injury
Care for accidental dental injury
Ambulance transport services

Home health care
High Option You pay nothing under High Option for the covered home health care services listed below for up to 90 days per calendar year if

1 the services rendered are billed by a home health care agency such as the hospital or a visiting nurse association that has a written agreement with the Local Plan to provide home health care
services and
2 prior approval is obtained from the Local Plan If prior approval is not obtained Other Medical Benefits will be provided as applicable

Note The member has the responsibility to make sure that the home health care provider has received prior approval from the Local Plan see pages 48 49 for instructions Please check with
your Local Plan and or your PPO directory for listings

What is covered Nursing care such as dressing changes injections and monitoring of vital signs Physical therapy
Respiratory or inhalation therapy
Prescription drugs
Medical supplies which serve a specific therapeutic or diagnostic purpose
Infusion therapy
Other medically necessary services or supplies that would have been provided by a hospital if the member was hospitalized

See page 28 for High Option coverage for physician home visits while receiving covered home health care services

What is not covered Home health care services related to the treatment of mental conditions substance abuse for routine maternity care for routine monitoring of a condition for intermittent care of a stable
condition or for initial evaluation of the patient to determine whether or not home health care is appropriate

Homemaking services including housekeeping preparing meals or acting as a companion or sitter

Standard Option See page 29 for Standard Option coverage of home nursing care

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider
32 When no PPO provider is available non PPO benefits apply 32
32 Page 33 34
Blue Cross and Blue Shield Service Benefit Plan 2000
Home hospice care You pay nothing under High and Standard Options if prior approval is obtained from the Local Plan for covered home hospice services rendered to members with a life expectancy of six months or
less when billed by a home hospice care agency which is approved by the Local Plan
Note You are responsible to make sure that the home hospice care provider has received prior approval from the Local Plan see page 48 for instructions Please check with your Local Plan

and or your PPO directory for listings

What is covered Physician visits Services of home health aides Nursing care Durable medical equipment rental
Medical social services Prescription drugs Physical therapy Medical supplies

Related inpatient Inpatient hospice benefits are available only to a member receiving Home hospice care benefits
services Benefits are provided for up to five 5 consecutive days in a hospital or a freestanding hospice inpatient facility These covered inpatient hospice benefits are available only when inpatient
services are necessary to control pain and manage the symptoms of the patient or to provide an interval of relief to the family respite

Each inpatient stay must be separated by at least 21 days You pay nothing under High and Standard Options when you are admitted to a Preferred hospital If you are admitted to a Member
or Non member hospital you pay 100 per admission deductible under High Option and you pay a 250 per admission deductible under Standard Option See page 15 for Inpatient Hospital
Benefits

What is not covered Homemaker or bereavement services
Limited benefits

Skilled nursing When Medicare Part A is primary payer it pays first and has made payment High and Standard
facilities Options provide secondary benefits for the applicable Medicare Part A copayments incurred in full during the first through the 30th day of confinement for each benefit period as defined by Medicare

in a qualified skilled nursing facility see page 9 If Medicare pays the first 20 days in full Plan benefits will begin on the 21st day when Medicare Part A copayments begin and will end on the

30th day
24 Hour nurse Help with health concerns is available 24 hours a day 365 days a year by calling a toll free
telephone service telephone number 1 888 258 3432 or accessing an Internet web site www Bluehealth org The service called Blue Health Connection features health advice or health information and counseling

by registered nurses Also available is the AudioHealth Library with hundreds of tapes ranging from first aid to infectious diseases to general health issues You can get information about health

care resources to help you find local doctors hospitals or other health care services affiliated with the Blue Cross and Blue Shield Service Benefit Plan This service is offered in certain pilot areas
and will become available in additional areas during 2000 Contact us at the number above or visit our web site for more information

We will send a membership kit and other information about Blue Health Connection in the mail to enrollees who live in the states where this service is available

Patient support The Service Benefit Plan is developing and may offer patient support programs for certain diagnoses
programs in select locations on a pilot basis

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider 33 When no PPO provider is available non PPO benefits apply 33
33 Page 34 35
Blue Cross and Blue Shield Service Benefit Plan 2000
Prescription Drug Benefits
What is covered You may purchase up to a 90 day supply of the following medications and supplies prescribed by a doctor from either a pharmacy or by mail however quantities may be limited for certain drugs such
as narcotics
Drugs vitamins and minerals and nutritional supplements that by Federal law of the United States require a doctor's prescription for their purchase

Insulin Needles and disposable syringes for the administration of covered medications
Intrauterine devices IUDs Norplant Depo Provera diaphragms and oral contraceptives dispensed by a retail pharmacy and oral contraceptives obtained through the Mail Service
Prescription Drug Program
Drugs to aid smoking cessation that require a prescription by Federal law limited to one regimen per calendar year

In most cases refills cannot be obtained until 75 of the drug has been used Call the Retail Pharmacy Program 1 800 624 5060 TDD 1 800 624 5077 or the Mail Service Prescription Drug
Program 1 800 262 7890 TDD 1 800 446 7292 for exceptions to this policy Not all drugs are available through the Mail Service Program

You can save money by using generic drugs By submitting your prescription or those of family members covered by the Plan to your retail pharmacy or the Mail Service Prescription Drug
Program you authorize them to substitute a Federally approved generic equivalent if available unless you or your physician specifically requests a name brand

What is not covered Medical supplies such as dressings and antiseptics Drugs and supplies for cosmetic purposes
Medication that does not require a prescription under Federal law even if your doctor prescribes it or a prescription is required under your State law

Drugs prescribed for weight loss Drugs for orthodontic care dental implants and periodontal disease
Drugs for which prior approval has been denied

From a pharmacy You may purchase up to a 90 day supply of covered drugs and supplies through the Retail Pharmacy Program Call 1 800 624 5060 TDD 1 800 624 5077 to locate a Preferred pharmacy in your area
High Option Standard Option
PPO Preferred You pay 15 PPA You pay 25 PPA retail pharmacies

Non preferred retail You pay 35 AWP You are You pay 45 AWP You are pharmacies also responsible for the also responsible for the
difference between the Plan's difference between the Plan's payment and the pharmacy's payment and the pharmacy's
actual charge actual charge
You must present your Plan ID card at the time of purchase at a Preferred pharmacy You are only responsible for the applicable coinsurance at the time of purchase All Preferred retail pharmacies
will file claims for you Preferred pharmacies will receive the payment and agree to accept 100 of the PPA as payment in full At Non preferred retail pharmacies you must pay the full cost at the
time of purchase and submit a claim You are responsible for the applicable coinsurance based upon the Average Wholesale Price AWP and any amounts in excess of the allowance Certain
prescription drugs and supplies may require prior approval see pages 35 and 48 49 Any savings received by the Carrier on the cost of drugs purchased under this Plan from drug manufacturers are
credited to the reserves held for this Plan

34 The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider When no PPO provider is available non PPO benefits apply 34
34 Page 35 36
Blue Cross and Blue Shield Service Benefit Plan 2000
To claim benefits Use a retail prescription drug claim form for prescription drugs and supplies purchased at Nonpreferred retail pharmacies You may obtain these forms by calling 1 800 624 5060 TDD
1 800 624 5077 Follow the instructions on the form and mail it to the Blue Cross and Blue Shield Service Benefit Plan Retail Pharmacy Program P O Box 52057 Phoenix AZ 85072 2057

By mail If your doctor orders more than a 21 day supply of covered drugs or supplies up to a 90 day supply you may order your prescription or refill by mail from the Mail Service Prescription Drug Program
Merck Medco Rx Services will fill your prescription
You pay an 8 generic and 14 brand name copayment under High Option and a 12 generic and 20 brand name copayment under Standard Option for each prescription drug supply or refill you

purchase through the Mail Service Prescription Drug Program
To claim benefits The Plan will send you information on the Mail Service Prescription Drug Program To use the Program
1 Complete the initial mail order form 2 Enclose your prescription and copayment

3 Mail your order to Merck Medco Rx Services P O Box 30492 Tampa FL 33633 0144 4 Allow approximately two weeks for delivery

Alternatively your physician may call in your initial prescription at 1 800 262 7890 TDD 1 800 446 7292 You will be billed later for the copayment After that to order your refill you
may either call the same number or access this Plan's website at http www fepblue org and either charge your copayment to your credit card or have it billed to you later You should allow
approximately one week for delivery
Prior approval Certain prescription drugs and supplies may require prior approval before they will be covered under this Plan and prior approval must be renewed periodically Call 1 800 624 5060 TDD
1 800 624 5077 to obtain an updated list of prescription drugs and supplies that require prior approval Once prior approval has been obtained or renewed you may take advantage of electronic

claims processing at Preferred pharmacies have claims paid for drugs and supplies purchased from Non preferred pharmacies or have drugs and supplies dispensed by the Mail Service Prescription
Drug Program
Retail Pharmacy The Retail Pharmacy Program will request the medical evidence needed to make its coverage
Program determination Drugs and supplies that require prior approval also require 1 payment in full at time of purchase including Preferred pharmacies and 2 the member's submission of the expense s on a

claim form Preferred pharmacies will not file these expenses for you

Mail Service Merck Medco Rx Services will screen all prescription drugs prior to dispensing If the drug or
Program supply requires prior approval your prescription will not be filled until prior approval has been obtained The prescription will be returned to you along with a Prior Approval Request form and a

letter explaining the program and procedures

Drugs from other Prescription drugs and certain supplies not purchased from a retail pharmacy or through the Mail Service Prescription Drug Program are covered at Other Medical Benefits levels when billed for by
sources an outpatient facility or a physician see pages 26 28 or Additional Benefits levels when billed for by a covered home health care agency see page 32 or home hospice agency see page 33 When

hospitalized drugs and supplies are covered under Inpatient Hospital Benefits see page 15 or Maternity Benefits see page 22

Purchasing drugs Claims for covered prescription drugs and supplies purchased outside of the United States and
when you are Puerto Rico should be submitted on an Overseas Claim Form and sent to the Overseas Claims Section address listed on page 40 These drugs must be equivalent to drugs that by Federal law of
overseas the United States require a prescription Prescription drugs requiring constant refrigeration cannot be shipped to APO FPO boxes by the Mail

Service Prescription Drug Program
Coordinating with When you use a Preferred retail pharmacy and this Plan is the primary payer you must call the Blue Cross and Blue Shield Service Benefit Plan Retail Pharmacy Program at 1 800 624 5060 TDD
other drug coverage 1 800 624 5077 to request a statement of benefits for other coverage purposes

The non PPO benefits are the standard benefits of this plan PPO benefits apply only when you use a PPO provider 35 When no PPO provider is available non PPO benefits apply 35
35 Page 36 37
Blue Cross and Blue Shield Service Benefit Plan 2000
Standard Option Dental Benefits
What is covered The Plan will pay Billed charges for the following services up to the amount specified in the Schedule of Dental Allowances below This is a complete list of covered dental benefits for
Standard Option These benefits are not available under High Option

Preferred Dental The PPO now includes Preferred dentists who are available in all Local Plans in most areas
Network Preferred dentists agree to accept a negotiated discount amount called the Maximum Allowable Charge MAC as payment in full for the services listed below These dentists may not be Preferred

for other services covered by this Plan under other benefit provisions such as oral and maxillofacial surgery or Other Medical Benefits They will also file your dental claims for you You are

responsible as an out of pocket expense for the difference between the amount specified on this Schedule of Dental Allowances and the MAC To find a Preferred dentist near you or to obtain a
copy of the MAC listing applicable to your area contact your Local Plan
Complete schedule of ADA Up to Age 13
dental allowances Code Age 13 and over

Clinical oral 0120 Periodic oral evaluation 12 8
evaluations 0140 Limited oral evaluation 14 9 0150 Comprehensive oral evaluation 14 9

0160 Detailed and extensive oral evaluation 14 9

Radiographs 0210 Intraoral complete series 36 22 0220 Intraoral periapical first film 7 5
0230 Intraoral periapical each additional film 4 3 0240 Intraoral occlusal film 12 7

0250 Extraoral first film 16 10 0260 Extraoral each additional film 6 4
0270 Bitewing single film 9 6 0272 Bitewings two films 14 9
0274 Bitewings four films 19 12 0277 Bitewings vertical 12 7
0290 Posterior anterior or lateral skull and facial bone survey film 45 28
0330 Panoramic film 36 23

Tests and laboratory 0460 Pulp vitality tests 11 7
exams

Palliative treatment 9110 Palliative emergency treatment of dental pain minor procedure 24 15
2940 Sedative filling 24 15

Preventive 1120 Prophylaxis child 22 14 1110 Prophylaxis adult 16
1201 Topical application of fluoride including prophylaxis child 35 22

1203 Topical application of fluoride prophylaxis not included child 13 8
1205 Topical application of fluoride including prophylaxis adult 24
1204 Topical application of fluoride prophylaxis not included adult 8

Space maintenance 1510 Space maintainer fixed unilateral 94 59
passive appliances 1515 Space maintainer fixed bilateral 139 87 1520 Space maintainer removable unilateral 94 59

1525 Space maintainer removable bilateral 139 87 1550 Recementation of space maintainer 22 14

Limited to two per person per calendar year

36 36
36 Page 37 38
Blue Cross and Blue Shield Service Benefit Plan 2000
ADA Up to Age 13 Code Age 13 and over
Amalgam 2110 Amalgam one surface primary 22 14
restorations 2120 Amalgam two surfaces primary 31 20
including 2130 Amalgam three surfaces primary 40 25
polishing 2131 Amalgam four or more surfaces primary 49 31 2140 Amalgam one surface permanent 25 16
2150 Amalgam two surfaces permanent 37 23 2160 Amalgam three surfaces permanent 50 31

2161 Amalgam four or more surfaces permanent 56 35

Filled or unfilled 2330 Resin one surface anterior 25 16
resin restorations 2331 Resin two surfaces anterior 37 23 2332 Resin three surfaces anterior 50 31

2335 Resin four or more surfaces or involving incisal angle anterior 56 35

2380 Resin one surface posterior primary 22 14 2381 Resin two surfaces posterior primary 31 20
2382 Resin three or more surfaces posterior primary 40 25 2385 Resin one surface posterior permanent 25 16
2386 Resin two surfaces posterior permanent 37 23 2387 Resin three surfaces posterior permanent 50 31
2388 Resin four or more surfaces posterior permanent 50 31

Inlay restorations 2510 Inlay metallic one surface 25 16 2520 Inlay metallic two surfaces 37 23
2530 Inlay metallic three or more surfaces 50 31 2610 Inlay porcelain ceramic one surface 25 16

2620 Inlay porcelain ceramic two surfaces 37 23 2630 Inlay porcelain ceramic three or more surfaces 50 31
2650 Inlay composite resin one surface 25 16 2651 Inlay composite resin two surfaces 37 23
2652 Inlay composite resin three or more surfaces 50 31

Other restorative 2951 Pin retention per tooth in addition to restoration 13 8
services Extractions includes
7110 Single tooth 30 19
local anesthesia and 7120 Each additional tooth 27 17
routine post operative 7130 Root removal exposed roots 71 45
care

Surgical extractions 7210 Surgical removal of erupted tooth requiring elevation
includes local of mucoperiosteal flap and removal of bone and or
anesthesia and routine section of tooth 43 27
post operative care 7250 Surgical removal of residual tooth roots cutting procedure 71 45

Anesthesia 9220 General anesthesia in connection with covered extractions 43 27

Oral and maxillofacial For covered oral and maxillofacial surgery or dental care related to accidental injury see pages 19
surgery or accidental and 29
injury Note Please check the Preferred status of your dentist or oral surgeon before receiving oral surgery A Preferred dentist who accepts the MAC as payment in full for the dental services listed above may

not be a Preferred provider for oral surgical procedures or other services covered under other benefit provisions of this Plan

What is not covered Any dental procedures or drugs involving orthodontic care the teeth dental implants periodontal disease or preparing the mouth for the fitting or the continued use of dentures except as specifically
described or referenced See General Exclusions

37 37
37 Page 38 39
Blue Cross and Blue Shield Service Benefit Plan 2000
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 of this Plan The cost of the benefits described on this page is not included in the FEHB premium and any charges for these services do not count toward any FEHB deductibles out of pocket maximum
copayment charges etc These benefits are not subject to the FEHB disputed claims review procedure
Vision Care Program Discount Vitamin Program
Service Benefit Plan members may obtain eye exams and Service Benefit Plan members may obtain a selection of over eyewear at substantial savings from Cole Managed Vision One 150 non prescription vitamins minerals and herbal products

providers The names addresses and telephone numbers of at a substantial savings when ordered through Bio Balance a Vision One providers are available by calling mail order discount program offered by Landmark Leiner

1 800 551 3337 Location information is available 24 hours a Health Products You may order products or request a catalog day Customer Service is available from 9 00 a m to 9 00 p m by calling 1 877 258 7283 Customer Service is available
EST Monday through Friday and from 9 00 a m to 5 00 p m from 8 00 a m to 9 00 p m EST Monday through Friday and EST Saturday from 8 00 a m to 6 00 p m EST Saturday

You may also obtain your contact lenses through the Vision There are no enrollment fees and no additional paperwork or One Contact Lens Replacement Program Call claim forms to be filed in this program All charges for
products offered by the Discount Vitamin Program are
1 800 987 5367 and ask for Dept 701 handled directly between you and Bio Balance

There are no enrollment fees and no additional paperwork or claim forms to be filed in this program All charges for eye

exams and eyewear are handled directly between you and the Vision One provider

Federal DentalBlue Medicare Prepaid Plan Enrollment Standard Option Only
Many local Blue Cross and Blue Shield Plans offer Medicare Federal DentalBlue is an optional dental product with an recipients the opportunity to enroll in a Medicare prepaid plan

additional premium that supplements the dental benefits without payment of an FEHB premium Contact your local included in your Standard Option coverage To apply for Blue Cross and Blue Shield Plan to find out if a Medicare
Federal DentalBlue you must be enrolled in Standard prepaid plan is available in your area and the cost if any of Option and reside in a Plan area listed below To purchase that enrollment
this additional coverage complete and sign the Federal DentalBlue enrollment form which you can obtain from your
Local Plan
Federal DentalBlue is available only in the following Plan areas

Alabama Oklahoma
Massachusetts
Washington areas served by the Regence Plan
Many Blue Cross and Blue Shield Plans not offering Federal DentalBlue do offer dental insurance outside and apart from

the FEHB Program If interested contact your Local Plan about availability of a non FEHB dental program in your area

The Blue Cross and Blue Shield Association and participating Local Plans will receive remuneration from Landmark Leiner Health Products to cover administrative costs in offering the program and for other purposes
Benefits on this page are not part of the FEHB contract

38 38
38 Page 39 40
Blue Cross and Blue Shield Service Benefit Plan 2000
Section 6 How to file a claim
Claim forms For claim forms and other claims filing advice contact your Local Plan If you do not receive your identification card s within 60 days after the effective date of your enrollment you may contact the
identification Local Plan serving the area in which you reside or write to FEP Enrollment Services 550 12th
cards Street SW Washington DC 20065 1463 to report the delay in receiving your card s to get replacement cards to obtain your Plan identification number or to obtain claim forms or other
and questions claims filing advice Give your full name address date of birth agency where employed whether enrollment is for Self Only or Self and Family whether High or Standard Option and

identification R number if known In the meantime use your copy of the SF 2809 enrollment form or your annuitant confirmation letter from OPM as proof of enrollment when you obtain
services
If you have a question concerning Plan benefits contact your Local Plan You may also contact the Plan at its website at http www fepblue org

If you made your open season change by using Employee Express and have not received your new ID card by the effective date of your enrollment call the Employee Express HELP number to
request a confirmation letter Use that letter to confirm your new coverage with providers
How to claim benefits Claims filed by your doctor that include an assignment of benefits to the doctor are to be filed on the form HCFA 1500 Health Insurance Claim Form Claims submitted by enrollees may be submitted
on the HCFA 1500 or a claim form that includes the information shown below Bills and receipts should be itemized and show

Name of patient and relationship to enrollee
Plan identification number of the enrollee
Name and address of person or firm providing the service or supply
Dates that services or supplies were furnished
Type of each service or supply and the charge
Diagnosis

In addition

A copy of the explanation of benefits EOB from any primary payer such as the Medicare Summary Notice MSN must be sent with your claim

Bills for home nursing care must show that the nurse is a registered or licensed practical nurse
Claims for rental or purchase of durable medical equipment private duty nursing and physical occupational and speech therapy require a written statement from the doctor specifying the

medical necessity for the service or supply and the length of time needed
Claims for prescription drugs and supplies that are not ordered through the Mail Service Prescription Drug Program must include receipts that include the prescription number name of

drug or supply prescribing physician's name date and charge
Translation and currency conversion services will be provided by the Plan for claims for overseas foreign services

Canceled checks cash register receipts or balance due statements are not acceptable
Contact your Local Plan at the telephone number on the back of your identification card for information claim forms and assistance

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

Submit All claims must be submitted no later than December 31 of the calendar year after the one in which
claims the covered care or service was provided unless timely filing was prevented by administrative
promptly operations of Government or legal incapacity provided the claim was submitted as soon as reasonably possible Once benefits have been paid there is a three year limitation on the reissuance of uncashed checks

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Blue Cross and Blue Shield Service Benefit Plan 2000
Use a separate claim form for each family member These procedures include prescription drugs that are not obtained from a retail pharmacy See below for a description of how to claim benefits
for retail pharmacy obtained prescription drugs When covered expenses exceed the deductible complete a claim form attach itemized bills and send them to the Local Plan serving the area where
the services were rendered For services other than inpatient you may send the claim to the Local Plan serving the area where you reside File expenses quarterly thereafter Claims payments for
covered services submitted by you are usually sent to you
If the Local Plan returns a claim or part of a claim for additional information it must be resubmitted within 90 days or before the timely filing period expires whichever is later For long or continuing

hospital stays or other long term care claims must be submitted at least every 30 days
For information about prescription drugs including insulin insulin related disposable syringes and other diabetic and non diabetic supplies obtained through the Mail Service Prescription Drug

Program see instructions on page 34 35

Overseas claims For covered services rendered in hospitals outside the United States and Puerto Rico and performed by physicians outside the United States send a completed Overseas Claim Form and the itemized
bills to NCA Processing Department 550 12th Street SW Washington DC 20065 8473 Attention FEP Overseas Claims Section Overseas Claim Forms can be obtained from this address

or your Local Plan Any written inquiries concerning the processing of overseas claims should be sent to this address

Preferred and Present your identification card when admitted or when you receive outpatient care The hospital
Member hospitals and has the necessary forms and will submit them to the Local Plan Benefits are paid to the hospital which will bill you for any coinsurance copayments noncovered charges or any charges applied to
facilities your calendar year deductible
in the U S and Puerto
Rico

Preferred and Always ask if the physician is a Preferred or Participating physician for purposes of this Plan
Participating Present your identification card and sign the necessary forms Benefits are usually paid to the
physicians in the physician who will bill you for any coinsurance copayments noncovered services or any charges applied to your calendar year deductible
U S

Prescription drug When you use Preferred retail pharmacies show your Plan ID card You pay the applicable
claims Retail coinsurance for your prescription drug Preferred retail pharmacies will file your prescription drug claim for you Reimbursement for covered drugs will be sent to pharmacies Members who do not
Pharmacy Program have a valid Plan ID card who do not show their card at the time of purchase or who failed to receive prior approval when required will have to file a paper claim form to obtain benefits for drugs

purchased at Preferred pharmacies
For Non preferred retail pharmacy expenses you should use a retail prescription drug claim form to claim benefits for retail pharmacy obtained prescription drugs Prescription drug claim forms may

be obtained from Local Plans or by calling 1 800 624 5060 Hearing impaired members with TDD equipment can call 1 800 624 5077 Follow the instructions on the claim form and submit the
completed form to
Blue Cross and Blue Shield Service Benefit Plan Retail Pharmacy Program P O Box 52057
Phoenix AZ 85072 2057

When more Reply promptly when the Carrier requests information in connection with a claim If you do not respond the Carrier may delay processing or limit the benefits available
information is
needed Facilities of the Department of Veterans Affairs the Department of Defense and the Indian Health DVA facilities

DoD facilities and 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
Indian Health Service governing such facilities

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Blue Cross and Blue Shield Service Benefit Plan 2000
Section 7 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless we determine it is medically necessary to prevent diagnose or treat your illness or condition The fact that one of our covered providers
has prescribed recommended or approved a service or supply does not make it medically necessary or eligible for coverage under this Plan

We do not cover the Services drugs or supplies that are not medically necessary
following Services not required according to accepted standards of medical dental or psychiatric practice in the United States
Experimental or investigational procedures treatments drugs or devices
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
Procedures services drugs and supplies related to sex transformations sexual dysfunction or sexual inadequacy

Services or supplies you receive from a provider or facility barred from the FEHB Program
Expenses you incurred while you were not enrolled in this Plan
Services where no charge would have been made if the covered individual had no health insurance coverage

Services furnished without charge except as described on page 40 while in active military service or required for illness or injury sustained on or after the effective date of enrollment 1
as a result of an act of war within the United States its territories or possessions or 2 during combat

Services furnished by immediate relatives or household members such as spouse parent child brother or sister by blood marriage or adoption
Services furnished or billed by a noncovered facility except that medically necessary prescription drugs are covered
Services not specifically listed as covered
Services or supplies used for cosmetic purposes
Any portion of a provider's fee or charge ordinarily due from the enrollee but that has been waived If a provider routinely waives does not require the enrollee to pay a deductible

copay or coinsurance the Carrier will calculate the actual provider fee or charge by reducing the fee or charge by the amount waived

Charges the enrollee or Plan has no legal obligation to pay such as excess charges for an annuitant age 65 or older who is not covered by Medicare Parts A and or B see pages 46 47
doctor charges exceeding the amount specified by the Department of Health and Human Services when benefits are payable under Medicare limiting charge see page 44 or State
premium taxes however applied
In the case of inpatient care medical services which are not medically necessary i e those which did not require the acute hospital inpatient overnight setting but could have been

provided in a physician's office the outpatient department of a hospital or some other setting without adversely affecting the patient's condition or the quality of medical care rendered
Some examples are
admissions for or consisting primarily of observation and or evaluation that could have been provided safely and adequately in some other setting e g physician's office

admissions primarily for diagnostic studies X rays Magnetic Resonance Imagings MRIs laboratory and pathological services and machine diagnostic tests which could have been
provided safely and adequately in some other setting e g outpatient department of a hospital or physician's office

Standby physicians Biofeedback and other forms of self care or self help training
Outpatient cardiac rehabilitation except as offered through case management under the flexible benefits option
Any dental and oral surgical procedures or drugs involving orthodontic care the teeth dental implants periodontal disease or preparing the mouth for the fitting or the continued use of
dentures These are covered only as described under Standard Option Dental Benefits Dental care for accidental injury Hospitalization for dental work or Surgical Benefits for Oral and
maxillofacial surgery
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Blue Cross and Blue Shield Service Benefit Plan 2000
Orthodontic care for temporomandibular joint TMJ syndrome Custodial care see Definitions
Services and supplies furnished or billed by an extended care facility nursing home or other noncovered facility except as specifically described on page 33 Medically necessary
prescription drugs are covered
Eyeglasses contact lenses routine eye examinations or vision testing for the prescribing or fitting of eyeglasses or contact lenses except as provided for on page 29

Eye exercises visual training or orthoptics except for nonsurgical treatment of amblyopia and strabismus as described on page 29
Hearing aids or examinations for the prescribing or fitting of hearing aids Treatment including drugs of obesity weight reduction or dietary control except for gastric
bypass surgery or gastric stapling procedures
Personal comfort items such as beauty and barber services radio television or telephone Routine services see Definitions except for those Preventive services specifically described in

this brochure on pages 26 28 and 31 For purposes of this Plan routine services include but are not limited to periodic physical examinations screening examinations or tests
immunization shots and X rays Magnetic Resonance Imagings MRIs laboratory and pathological services and machine diagnostic tests that are not related to a specific diagnosis
illness injury set of symptoms or maternity care
Routine foot care including corn or callus removal or nail trimming Recreational or educational therapy and any related diagnostic testing except as provided by a

hospital as part of a covered inpatient stay or through an approved Home health care program
Assisted Reproductive Technology ART procedures and related services and supplies see page 23

Services you receive from noncovered providers such as chiropractors except as specifically described on page 10 under Coverage in medically underserved areas

Section 8 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On occasion
you may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled with us

If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a Medicare Choice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a Medicare Choice plan contact your retirement office If you later want to re enroll in the FEHB Program generally you may do so only at the next Open Season

If you involuntarily lose coverage or move out of the Medicare Choice service area you may reenroll in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration SSA office or call SSA at 1 800 638 6833 For information on the Medicare Choice plan s offered by
local Blue Cross and Blue Shield Plans see page 38

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Blue Cross and Blue Shield Service Benefit Plan 2000
Coordinating The following information applies only to enrollees and covered family members who are entitled to benefits from both this Plan and Medicare You must disclose information about Medicare
benefits coverage including your enrollment in a Medicare prepaid plan to us this applies whether or not you file a claim under Medicare You must also give us authorization to obtain information about

benefits or services denied or paid by Medicare when we request it It is also important that you inform us about other coverage you may have as this coverage may affect the primary secondary
status of this Plan and Medicare see pages 42 44
This Plan covers most of the same kinds of expenses as Medicare Part A hospital insurance except that primary benefits are not available from this Plan for qualified skilled nursing facility care and

Part B medical insurance except that Medicare does not cover prescription drugs
The following rules apply to enrollees and their family members who are entitled to benefits from both an FEHB plan and Medicare

This Plan is 1 You are age 65 or over have Medicare Part A or Parts A and B and are employed by the Federal Government
primary if 2 Your covered spouse is age 65 or over and has Medicare Part A or Parts A and B and you are employed by the Federal Government

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

4 The patient you or a covered family member is under age 65 and eligible for Medicare solely on the basis of disability and you are employed by the Federal Government
For purposes of this section employed by the Federal Government means that you are eligible for FEHB coverage based on your current employment and that you do not hold an appointment
described under Rule 6 of the following Medicare is primary section
Medicare is 1 You are an annuitant age 65 or over covered by Medicare Part A or Parts A and B and are not employed by the Federal Government
primary if 2 Your covered spouse is age 65 or over and has Medicare Part A or Parts A and B and you are not employed by the Federal Government

3 You are age 65 or over and a you are a Federal judge who retired under title 28 U S C b you are a Tax Court judge who retired under Section 7447 of title 26 U S C or c you are the
covered spouse of a retired judge described in a or b
4 You are an annuitant not employed by the Federal Government and either you or a covered family member who may or may not be employed by the Federal Government is under age 65

and eligible for Medicare on the basis of disability
5 You are enrolled in Part B only regardless of your employment status
6 You are age 65 or over and employed by the Federal Government in an appointment that excludes similarly appointed nonretired employees from FEHB coverage and have Medicare

Part A or Parts A and B
7 You are a former Federal employee receiving workers compensation and the Office of Workers Compensation has determined that you are unable to return to duty

8 The patient you or a covered family member has completed the 30 month ESRD coordination period and is still eligible for Medicare due to ESRD or
9 The patient you or a covered family member becomes eligible for Medicare due to ESRD after Medicare assumed primary payer status for the patient under rules 1 through 7 above

When Medicare is primary all or part of your Plan deductibles copayments and coinsurance will be waived as follows
Inpatient Hospital Benefits If you are enrolled in Medicare Part A and Medicare is the primary payer the Plan will waive the per admission deductible applicable in Member and Non member
hospitals and the Non member hospital coinsurance The requirement to precertify each hospital admission is also waived also see pages 47 48 The Plan will not waive the difference between the
Average charge and the Billed charge see pages 50 52 at a Non member hospital once Medicare benefits have been exhausted If you are enrolled in Medicare Part B and Medicare is the primary
payer the Plan will waive the calendar year deductible and any coinsurance for inhospital physician care

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Blue Cross and Blue Shield Service Benefit Plan 2000
Surgical Benefits and Other Medical Benefits If you are enrolled in Medicare Part B and Medicare is the primary payer the Plan will waive the calendar year deductible any coinsurance or
outpatient facility copayments and the 12 copayment for each home and office visit physician outpatient consultation and second surgical opinion The Preferred Member and Non member
facility copayments for outpatient surgery are also waived
Maternity Benefits Deductibles copayments and coinsurance are waived the same as for Inpatient Hospital Benefits Surgical Benefits and Other Medical Benefits

Mental Conditions Substance Abuse Benefits If you are enrolled in Medicare Part A and Medicare is the primary payer the Plan will waive the inpatient hospital mental conditions substance
abuse per day copayments If you are enrolled in Medicare Part B and Medicare is the primary payer the Plan will waive the inpatient and outpatient professional care coinsurance outpatient
facility care copayments and the calendar year deductible Benefit limits will not be waived
Additional Benefits If you are enrolled in Medicare Part B and Medicare is the primary payer the 12 copayment for each preventive screening physical examination provided by a Preferred

physician or facility is waived
When Medicare is the primary payer this Plan will limit its payment to an amount that supplements the benefits that would be payable by Medicare regardless of whether or not Medicare benefits are

paid However the Plan will pay its regular benefits for emergency services to an institutional provider such as a hospital that does not participate with Medicare and is not reimbursed by
Medicare
If you are enrolled in Medicare you may be asked by a physician to sign a private contract agreeing that you can be billed directly for services that would ordinarily be covered by Medicare Should

you sign such an agreement Medicare will not pay any portion of the charges and you may receive less or no payment for those services under this Plan

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

Medicare's If you are covered by Medicare Part B and it is primary you should be aware that your out of pocket costs for services covered by both this Plan and Medicare Part B will depend on whether your doctor
payment and this accepts Medicare assignment for the claim
Plan Doctors who participate with Medicare accept assignment that is they have agreed not to bill you for more than the Medicare approved amount for covered services Some doctors who do not

participate with Medicare accept assignment on certain claims If you use a doctor who accepts Medicare assignment for the claim the doctor is permitted to bill you after the Plan has paid only
when the Medicare and Plan payments combined do not total the Medicare approved amount
Doctors who do not participate with Medicare are not required to accept direct payment or assignment from Medicare Although they can bill you for more than the amount Medicare would

pay Medicare law the Social Security Act 42 U S C sets a limit on how much you are obligated to pay This amount called the limiting charge is 115 percent of the Medicare approved amount
Under this law if you use a doctor who does not accept assignment for the claim the doctor is permitted to bill you after the Plan has paid only if the Medicare and Plan payments combined do
not total the limiting charge
Neither you nor your FEHB Plan is liable for any amount in excess of the Medicare limiting charge for charges of a doctor who does not participate with Medicare The Medicare Summary Notice

MSN will have more information about this limit
If your doctor does not participate with Medicare asks you to pay more than the limiting charge and he or she is under contract with this Plan call the Plan If your doctor is not a Plan doctor ask the

doctor to reduce the charge or report him or her to the Medicare carrier that sent you the Medicare Summary Notice MSN In any case a doctor who does not participate with Medicare is not
entitled to payment of more than 115 percent of the Medicare approved amount

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Blue Cross and Blue Shield Service Benefit Plan 2000
How to claim In most cases when services are covered by both Medicare and this Plan Medicare is the primary payer if you are an annuitant and this Plan is the primary payer if you are an employee When
benefits Medicare is the primary payer your claims should first be submitted to Medicare To be sure your claims are processed by this Carrier you must submit the Medicare Summary Notice MSN and

duplicates of all bills along with a completed claim form The Carrier will not process your claim without knowing whether you have Medicare and if you do without receiving the Medicare
Summary Notice MSN
Claims should show both your Plan identification number 8 digits preceded by R and your Medicare identification number which is on your Medicare card Claims for benefits which are not

covered by Medicare should be sent directly to your Local Plan See page 40 for information on how retail pharmacy obtained drug expenses are filed

Other group When anyone has coverage with us and with another group health plan it is called double coverage You must tell us if you or a family member has double coverage You must also send us documents
insurance about other insurance if we ask for them
coverage When you have double coverage one plan is the primary payer it pays benefits first The other plan is secondary it pays benefits next We decide which insurance is primary according to the National

Association of Insurance Commissioners Guidelines
If we pay second we will determine how much of the charge we will pay for After the first plan pays we will pay either what is left of our allowable charge or our regular benefit whichever is less

We will not pay more than our allowable charge When we pay secondary we will generally only make up the difference between the primary plan's benefit payment and 100 of our allowable
charge subject to our applicable deductibles coinsurance and copayments see pages 43 44 for exceptions when Medicare is primary payer Thus the combined payments from both plans may
not equal the entire amount billed by the provider In certain circumstances when we are secondary and there is no adverse effect on you we may also take advantage of any provider discount
arrangements the primary plan may have and only make up the difference between the primary plan's payment and the amount the provider has agreed to accept as payment in full from the primary
plan When we are secondary to primary coverage you may have from a prepaid plan our benefits will be based on your out of pocket liability under the prepaid plan generally the prepaid plan's
copayment subject to our deductibles coinsurance and copayments see page 44 for exceptions
Remember Even if you do not file a claim with your other plan you must still tell us that you have double coverage

When others are This subrogation and right of recovery provision applies when you or your dependent are sick or injured as a result of the act or omission of another person or party We have the right to recover
responsible for payments we have made to you or your dependent from a third party or third party's insurer because
injuries of illness or injury caused by a third party In addition to our right of recovery we are subrogated to you and your dependent's present and future claims against a third party Third party means another
person or organization
If you or your covered dependent suffer an injury or illness through the act or omission of another you and your dependent agree 1 to reimburse us for benefits we paid in an amount not to exceed

the amount of the recovery and 2 that we will be subrogated to your or your dependent's rights to the extent of the benefits paid including the right to bring suit All recoveries from a third party
whether by lawsuit settlement or otherwise must be used to reimburse us for benefits paid Our share of the recovery will not be reduced because you or your dependent do not receive the full
amount of damages claimed unless we agree in writing to a reduction

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Blue Cross and Blue Shield Service Benefit Plan 2000
When you or your dependent make a claim against a third party or the third party's insurer as a result of an injury or illness for which that third party is legally responsible we shall have a lien on the
proceeds of that claim in order to reimburse ourselves to the full amount of benefits we are called upon to pay Our lien will apply to any and all recoveries for such claim whether by court order or
out of court settlement
If you or your dependent are injured because of a third party's action or omission 1 we will pay benefits for that injury subject to the conditions that you and your dependent a do not take any

action that would prejudice our ability to recover benefits and b will cooperate in doing what is reasonably necessary to assist us in any recovery 2 our right of reimbursement extends only to the
amount of Plan benefits paid or to be paid because of the injury and 3 we may insist upon an assignment of the proceeds of the claim or right of action against the third party and may withhold
payment of benefits otherwise due until the assignment is provided
You are required to notify us promptly of any third party claim that you may have for damages for which we have paid or may pay benefits In addition you are required to notify us of any recovery

whether in or out of court that you or your dependent obtain and to reimburse us to the extent of benefits paid by us Any reduction of our claim for payment of attorney's fees or costs associated
with the claim is subject to prior approval by us
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you we are the
primary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE coverage

Workers We do not cover services that
compensation You need because of a workplace related disease or injury that the Office of Workers Compensation Programs OWCP or a similar Federal or State agency determine they must
provide
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws

Once the OWCP or similar agency has paid its maximum benefits for your treatment we will provide your benefits

Medicaid We pay first if both Medicaid and this Plan cover you
Other Government We do not cover services and supplies that a local State or Federal Government agency directly or indirectly pays for
Agencies

Overpayments We will make reasonably diligent efforts to recover benefit payments made erroneously but in good faith and may apply subsequent benefits otherwise payable to offset any overpayments
Limit on your costs The information in the following paragraphs applies to you when 1 you are not covered by either
if you're age 65 or Medicare Part A hospital insurance or Part B medical insurance or both 2 you are enrolled in this Plan as an annuitant or as a former spouse or family member covered by the family enrollment
older and don't of an annuitant or former spouse and 3 you are not employed in a position which confers FEHB
have Medicare coverage

Inpatient hospital If you are not covered by Medicare Part A are age 65 or older or become age 65 while receiving
care inpatient hospital services and you receive care in a Medicare participating hospital the law 5 U S C 8904 b requires the Plan to base its payment on an amount equivalent to the amount

Medicare would have allowed if you had Medicare Part A This amount is called the equivalent Medicare amount After the Plan pays the law prohibits the hospital from charging you for

covered services after you have paid any deductibles coinsurance or copayments you owe under the Plan Any coinsurance you owe will be based on the equivalent Medicare amount not the actual
charge You and the Plan together are not legally obligated to pay the hospital more than the equivalent Medicare amount

The Carrier's explanation of benefits EOB will tell you how much the hospital can charge you in addition to what the Plan paid If you are billed more than the hospital is allowed to charge ask the
hospital to reduce the bill If you have already paid more than you have to pay ask for a refund If you cannot get a reduction or refund or are not sure how much you owe call your Local Plan at the
telephone number on the back of your identification card for assistance

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Blue Cross and Blue Shield Service Benefit Plan 2000
Physician services Claims for physician services provided for retired FEHB members age 65 and older who do not have Medicare Part B are also processed in accordance with 5 U S C 8904 b This law mandates the use
of Medicare Part B limits for covered physician services for those members who are not covered by Medicare Part B

The Plan is required to base its payment on the Medicare approved amount which is the Medicare fee schedule for the service or the actual charge whichever is lower If your physician is a member
of the Plan's Preferred Provider Organization PPO and participates with Medicare the Plan will base its payment on the lower of these two amounts and you are responsible only for any deductible
and the PPO copayment or coinsurance
If you go to a PPO physician who does not participate with Medicare you are responsible for any deductible and the copayment or coinsurance In addition unless the provider's agreement with the

Local Plan specifies otherwise you must pay the difference between the Medicare approved amount and the limiting charge 115 of the Medicare approved amount

If your physician is not a Plan PPO physician but participates with Medicare the Plan will base its regular benefit payment on the Medicare approved amount For instance under this Plan's
Standard Option surgical benefit the Plan will pay 75 of the Medicare approved amount You will only be responsible for any deductible and coinsurance equal to 25 of the Medicare approved
amount
If your physician does not participate with Medicare the Plan will still base its payment on the Medicare approved amount However in most cases you will be responsible for any deductible the

coinsurance or copayment amount and any balance up to the limiting charge amount 115 of the Medicare approved amount

Since a physician who participates with Medicare is only permitted to bill you up to the Medicare fee schedule amount even if you do not have Medicare Part B it is generally to your financial
advantage to use a physician who participates with Medicare
The Carrier's explanation of benefits EOB will tell you how much the physician can charge you in addition to what the Plan paid If you are billed more than the physician is allowed to charge ask

the physician to reduce the bill If you have already paid more than you have to pay ask for a refund If you cannot get a reduction or refund or are not sure how much you owe call your Local
Plan at the telephone number on the back of your identification card for assistance

Section 9 Fee for Service Facts

Precertification Precertification evaluates the medical necessity of proposed admissions and the number of days required to treat your condition You are responsible for ensuring that the precertification
requirement is met You or your doctor must check with your Plan before being admitted to the hospital If that doesn't happen your Plan will reduce benefits by 500 Be a responsible consumer

Be aware of your Plan's cost containment provisions You can avoid penalties and keep premiums under control by following the procedures specified in this subsection

Precertify before Precertification is not a guarantee of benefit payments Precertification of an inpatient admission is a predetermination that based on the information given the admission meets the medical necessity
admission requirements of the Plan It is your responsibility to ensure that precertification is obtained If precertification is not obtained and benefits are otherwise payable benefits for the admission will be

reduced by 500 When you call to obtain precertification be sure also to verify whether the hospital is a Preferred Member or Non member hospital

To precertify a You your representative your physician or your hospital must call the Local Plan prior to
scheduled admission
admission Provide the following information enrollee's name and Plan identification number patient's name birth date and phone number reason for hospitalization proposed treatment or surgery

name of hospital or facility name and phone number of admitting physician and number of planned days of confinement

The Local Plan will then tell the physician and or hospital the number of approved days of confinement for the care of the patient's condition Written confirmation of the certification
decision will be sent to you your physician and the hospital If the length of stay needs to be extended follow the procedures below

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Blue Cross and Blue Shield Service Benefit Plan 2000
Need additional If any additional days are required your physician or the hospital must request certification for the
days additional days If the admission is precertified but you remain confined beyond the number of days certified as medically necessary the Plan will not pay for charges incurred on any extra days that are

determined not to be medically necessary by the Carrier during the claim review

You don't need to Medicare Part A or another group health insurance policy is the primary payer for the hospital
precertify an confinement see pages 43 and 45 Precertification is required however when Medicare
admission when hospital benefits are exhausted prior to using lifetime reserve days You are confined in a hospital outside the United States

Emergency When there is an emergency admission due to a condition that puts the patient's life in danger or
admissions could cause serious damage to bodily function you your representative the physician or the hospital must telephone the Local Plan within two business days following the day of admission

even if the patient has been discharged from the hospital Otherwise inpatient benefits otherwise payable for the admission will be reduced by 500

Maternity Precertification is not required for maternity admissions for routine deliveries However if your
admissions medical condition requires you to stay more than 48 hours after a vaginal delivery or 96 hours after a cesarean section your physician or the hospital must contact the Local Plan for certification of

additional days The Plan will not pay for charges incurred on any extra days that are not medically necessary Certification for additional days must also be requested for a covered newborn confined

beyond the mother's discharge date

Other An early determination of need for confinement precertification of the medical necessity of
considerations inpatient admission is binding on the Local Plan unless the Local Plan is misled by the information given to it After the claim is received the Local Plan will first determine whether the admission

was precertified and then provide benefits according to all of the terms of this brochure

If you do not If precertification is not obtained before admission to the hospital or within two business days
precertify following the day of an emergency admission a medical necessity determination will be made at the time the claim is filed If the Local Plan determines that the hospitalization was not medically

necessary the inpatient hospital benefits will not be paid However medical supplies and services otherwise payable on an outpatient basis will be paid

If the claim review determines that the admission was medically necessary any benefits payable according to all of the terms of this brochure will be reduced by 500 for failing to have the
admission precertified
If the admission is determined to be medically necessary but part of the length of stay was found not to be medically necessary inpatient hospital benefits will not be paid for the portion of the

confinement that was not medically necessary However medical services and supplies otherwise payable on an outpatient basis will be paid

Prior approval Before the following services are rendered you or your provider should contact 1 the Local Plan where the services will be rendered 2 the Retail Pharmacy Program for certain drugs and supplies
or 3 the Carrier for the clinical trials benefit for certain organ tissue transplant procedures for information and procedures for prior approval

Home health care High Option The Local Plan will request the medical evidence it needs to make its coverage determination see page 32
Home hospice care The Local Plan will request the medical evidence it needs to make its coverage determination see page 33
Organ tissue transplants The Local Plan will request the medical evidence it needs to make its coverage determination The Local Plan will consider whether the facility is approved for
the procedure and whether the patient meets the facility's criteria see page 19
Clinical trials for certain organ tissue transplants The Carrier will request the records it needs to make its coverage determination Inquiries and prior approval requests should be

directed to the Clinical Trials Information Unit of the Blue Cross and Blue Shield Association at 1 800 225 2268 see page 19 This number is for prior approval of clinical trials for bone
marrow and peripheral blood stem cell transplant support procedures for multiple myeloma breast cancer epithelial ovarian cancer chronic myelogenous leukemia chronic lymphocytic
leukemia and early stage indolent or non advanced small cell lymphocytic lymphoma only

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Blue Cross and Blue Shield Service Benefit Plan 2000
Prescription drugs and supplies The Retail Pharmacy Program will request the medical evidence it needs to make its coverage determination Drugs and supplies that require prior
approval also require 1 payment in full at time of purchase including Preferred pharmacies and 2 the member's submission of the expense s on a claim form Preferred pharmacies will
not file these expenses for you
Protection Against
Catastrophic Costs Catastrophic For services with coinsurance or copayments other than those shown below as excluded from this

protection Catastrophic Protection Benefit you pay nothing for Covered charges for the remainder of the calendar year if out of pocket expenses for certain coinsurance copayments the calendar year
deductible and per admission deductibles in that calendar year exceed 2,700 High Option or 3,750 Standard Option for you and any covered family members

Preferred When your eligible out of pocket expenses as discussed above from using Preferred providers
providers when the services are eligible to be received from Preferred providers exceed 1,000 High Option or 2,000 Standard Option you pay nothing for Covered charges for covered expenses

when you continue to select Preferred providers for the remainder of the calendar year Whether or not you use Preferred providers your share of out of pocket expenses will not exceed 2,700 High

Option or 3,750 Standard Option in a calendar year

Out of pocket Out of pocket expenses for the purposes of this benefit are
expenses The calendar year deductible of 150 High Option or 200 Standard Option The per admission deductible of 100 High Option or 250 Standard Option you pay for

inpatient Non preferred hospital care
The 10 High Option and 25 Standard Option copayments that you pay for outpatient facility care and outpatient facility surgical care in Preferred facilities under Other Medical

Benefits
The 50 High Option and 100 Standard Option copayments that you pay for outpatient facility care and outpatient facility surgical care in Member facilities under Other Medical

Benefits
The 5 PPA High Option and 10 PPA Standard Option coinsurance you pay for care provided by Preferred physicians the 20 PAR High Option and 25 PAR Standard

Option coinsurance you pay for care provided by Participating physicians and the 20 NPA High Option and 25 NPA Standard Option coinsurance you pay for care provided by
Non participating physicians and other covered professionals under Inpatient Hospital Benefits Surgical Benefits Maternity Benefits and Other Medical Benefits

The 12 copayment under High and Standard Options that you pay for each home and office visit physician's outpatient consultation and second surgical opinion when provided by a
Preferred physician under Other Medical Benefits Physician care or each preventive screening physical examination when provided by a Preferred physician or Preferred facility
under Additional Benefits Preventive services provided by Preferred providers
The 15 PPA High Option and 25 PPA Standard Option coinsurance you pay for pharmacy obtained drugs when provided by a Preferred pharmacy and 35 AWP High

Option and 45 AWP Standard Option coinsurance you pay for pharmacy obtained drugs when provided by a Non preferred pharmacy under Prescription Drug Benefits and

Mail Service Prescription Drug copayments
The following expenses are not included under this Catastrophic Protection Benefit They are not counted toward eligible out of pocket expenses and are not payable by the Plan when the

Catastrophic Protection Benefit out of pocket limits have been reached
Expenses in excess of Allowable charges or maximum benefit limitations
The 30 of the Non member rate coinsurance you pay for Non member inpatient facility care
The 100 High Option and 150 Standard Option copayments you pay for Non member outpatient facility care

Expenses for Mental Conditions Substance Abuse Benefits or Dental Benefits and

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Blue Cross and Blue Shield Service Benefit Plan 2000
Any amounts you pay because benefits have been reduced for non compliance with this Plan's cost containment requirements see pages 47 48

Carryover If you changed to this Plan during open season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1 any expenses that would have applied to that
plan's catastrophic protection benefit during the prior year will be covered by your old plan if they are for care you got in January before the effective date of your coverage in this Plan If you have

already met the covered out of pocket maximum expense level in full your old plan's catastrophic protection benefit will continue to apply until the effective date If you have not met this expense
level in full your old plan will first apply your covered out of pocket expenses until the prior year's catastrophic level is reached and then apply the catastrophic protection benefit to covered out ofpocket
expenses incurred from that point until the effective date The old plan will pay these covered expenses according to this year's benefits benefit changes are effective on January 1

If you change options in this Plan during the calendar year the amounts already accumulated toward the PPO and Non PPO catastrophic protection out of pocket limits of your old option will be
credited to the out of pocket limits of your new option

Definitions
Accidental injury An injury caused by an external force or element such as a blow or fall and which requires immediate medical attention including animal bites and poisonings
Dental care for accidental injury is limited to dental treatment necessary to repair sound natural teeth Injury to the teeth while eating is not considered an accidental injury

Admission The period from entry admission into a hospital or other covered facility until discharge In counting days of inpatient care the date of entry and the date of discharge are counted as the
same day

Allowable charge See Covered charges
Anesthesia service The administration by injection or inhalation of a drug or other anesthetic agent including acupuncture to obtain muscular relaxation loss of sensation or loss of consciousness

Assignment An authorization by an enrollee or spouse for the Carrier to issue payment of benefits directly to the provider The Carrier reserves the right to pay the member directly for all covered services
Average charge See Covered charges
Average Wholesale See Covered charges
Price AWP

Billed charge See Covered charges
Calendar year January 1 through December 31 of the same year For new members the calendar year begins on the effective date of their enrollment and ends on December 31 of the same year

Carrier The Blue Cross and Blue Shield Association on behalf of local Blue Cross and Blue Shield Plans
Collateral visit A session to confirm the patient's diagnosis and establish a treatment plan and during the course of treatment to evaluate the patient's response to treatment

Concurrent care Hospital inpatient care by a physician other than the attending physician 1 for a condition not related to the primary diagnosis or 2 because the medical complexity of the patient's condition
requires additional medical care

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Blue Cross and Blue Shield Service Benefit Plan 2000
Congenital anomaly A condition existing at or from birth which is a significant deviation from the common form or norm For purposes of this Plan congenital anomalies include protruding ear deformities cleft lips
cleft palates birthmarks webbed fingers or toes and other conditions that the Carrier may determine to be congenital anomalies In no event will the term congenital anomaly include conditions relating

to teeth or intra oral structures supporting the teeth

Cosmetic surgery Any operative procedure or any portion of a procedure performed primarily to improve physical appearance and or treat a mental condition through change in bodily form

Covered charges Charges for covered services The following are considered Covered charges Allowable charge There are four types of Allowable charges the Preferred Provider Allowance
PPA which applies to charges from Preferred professionals and pharmacies the Participating Provider Allowance PAR which applies to charges from Participating professional providers the

Non participating Provider Allowance NPA which applies to charges from Non participating professional providers and the Average Wholesale Price AWP which applies to charges from
Non preferred pharmacies If you are age 65 or older and not enrolled in Medicare this may not apply see pages 46 47 The definition of each Allowable charge is

Preferred Provider Allowance PPA A negotiated allowance most Preferred professionals and pharmacies agree to accept as payment in full when the Plan pays primary
benefits See pages 10 11 for information about Preferred physicians and acceptance of the Preferred Provider Allowance in your Local Plan area
Participating Provider Allowance PAR A negotiated allowance most Participating professionals agree to accept as payment in full when the Plan pays primary benefits See
pages 10 11 for information about Participating physicians and acceptance of the Participating Provider Allowance in your Local Plan area
Non participating Provider Allowance NPA An allowance equal to the greater of 1 the Medicare participating fee schedule amount for the service or supply in the geographic
area in which it was performed or obtained or 60 of the Billed charge if there is no equivalent Medicare fee schedule amount or 2 80 of the 2000 Usual Customary and
Reasonable UCR amount for the service or supply in the geographic area in which it was performed or obtained
Usual Customary and Reasonable UCR Profile Local Plans determine reimbursement for covered services by applying a profile
The profile is developed from the actual charges by providers in their area The profiles are generally updated annually however local exceptions may apply

Accepted allowance Local Plans may determine reimbursement for covered expenses based on an accepted allowance instead of a profile Accepted allowances are based on what
Participating providers are accepting as payment in full in the Local Plan area
Non participating physicians and other Non participating providers are under no obligation to accept the Plan's allowance as payment in full If you use Non participating providers

you will be responsible for the difference between the Plan's payment and the provider's charge including any applicable copayments coinsurance or deductibles

Average Wholesale Price AWP The average wholesale price of a drug on the date the drug is dispensed as set forth in the most current version of First DataBank's National Drug
Data File
Non preferred pharmacies are under no obligation to accept the Plan's allowance as payment in full If you use Non preferred pharmacies you will be responsible for the difference

between the Plan's payment and the pharmacy's charge including applicable coinsurance and deductibles

Average charge An amount established by the Local Plan for a Non member facility not to exceed the average semiprivate rate charged by similar institutions in the same area for inpatient
care A Non member facility is not required to accept the Average charge as payment in full
Billed charge Charges for covered services billed by a provider but see If provider waives your share on page 8 This amount may be different from the total amount submitted by the

provider because it does not include charges for noncovered services

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Blue Cross and Blue Shield Service Benefit Plan 2000
Member rate The negotiated amount of payment that the Local Plan has agreed is due to a Member facility from the Plan and the enrollee for a claim at the time the claim is processed
including any savings the Local Plan receives from discounts that are known and that can be accurately calculated at the time the claim is processed The Member rate may be subject to a
periodic adjustment that generally but not always decreases the negotiated amount of payment due to the facility for the claim If the payment is decreased the amount of the decrease is
credited to the reserves held for this Plan If the payment is increased the Plan pays that cost on behalf of the enrollee

Non member rate The Billed charge or the Average charge see page 51
Preferred rate The negotiated amount of payment that the Local Plan has agreed is due to a Preferred facility from the Plan and the enrollee for a claim at the time the claim is processed

including any savings the Local Plan receives from discounts that are known and that can be accurately calculated at the time the claim is processed The Preferred rate may be subject to a
periodic adjustment that generally but not always decreases the negotiated amount of payment due to the facility for the claim If the payment is decreased the amount of the decrease is
credited to the reserves held for this Plan If the payment is increased the Plan pays that cost on behalf of the enrollee

Custodial care Treatment or services regardless of who recommends them or where they are provided that could be rendered safely and reasonably by a person not medically skilled or that are designed mainly to
help the patient with daily living activities These activities include but are not limited to
1 personal care such as help in walking getting in and out of bed bathing eating by spoon tube or gastrostomy exercising dressing

2 homemaking such as preparing meals or special diets
3 moving the patient
4 acting as companion or sitter
5 supervising medication that can usually be self administered or
6 treatment or services that any person may be able to perform with minimal instruction including but not limited to recording temperature pulse and respirations or administration and

monitoring of feeding systems
The Carrier its medical staff and or an independent medical review determines which services are custodial care

Durable medical Equipment and supplies that
equipment 1 are prescribed by your physician 2 are medically necessary

3 are primarily and customarily used only for a medical purpose
4 are generally useful only to a person with an illness or injury
5 are designed for prolonged use and
6 serve a specific therapeutic purpose in the treatment of an illness or injury

Effective date The date the benefits described in this brochure are effective 1 January 1 for continuing enrollments and for all annuitant enrollments or

2 for enrollees who change plans or options or elect FEHB coverage during the open season for the first time and for new enrollees during the calendar year but not during the open season the
effective date of enrollment as determined by the employing office or retirement system
Enrollee The contract holder eligible for enrollment and coverage under the Federal Employees Health Benefits Program and enrolled in the Plan

Experimental or See page 12
investigational

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Blue Cross and Blue Shield Service Benefit Plan 2000
Group health Health care coverage that a member is eligible for because of employment by membership in or connection with a particular organization or group that provides payment for hospital medical or
coverage other health care services or supplies or that pays a specific amount for each day or period of hospitalization if the specified amount exceeds 200 per day including extension of any of these

benefits through COBRA

Home health care Medical care provided to homebound patients who require continuous active and skilled care at home

Home health care An organization that has a written agreement with the Local Plan to provide home health care services
agency

Home hospice care An integrated set of services and supplies designed to provide palliative and supportive care to terminally ill patients in their homes
program

Lifetime maximum The maximum amount the Plan will pay on your behalf for covered services rendered while you are enrolled in your option Benefit amounts accrued under High Option and Standard Option are
accumulated in a permanent record regardless of the number of enrollment changes

Local Plan A Blue Cross and Blue Shield Plan serving a specific geographic area
Medically necessary Services drugs supplies or equipment provided by a hospital or covered provider of health care services that the Carrier determines
1 are appropriate to diagnose or treat the patient's condition illness or injury
2 are consistent with standards of good medical practice in the United States
3 are not primarily for the personal comfort or convenience of the patient the family or the provider

4 are not a part of or associated with the scholastic education or vocational training of the patient and
5 in the case of inpatient care cannot be provided safely on an outpatient basis
The fact that a covered provider has prescribed recommended or approved a service supply drug or equipment does not in itself make it medically necessary

Member rate See Covered charges
Members Enrollees and family members eligible for coverage under the Federal Employees Health Benefits Program and enrolled in the Plan

Mental conditions Conditions and diseases listed in the most recent edition of the International Classification of Diseases ICD as psychoses neurotic disorders or personality disorders other nonpsychotic mental
substance abuse disorders listed in the ICD to be determined by the Carrier or disorders listed in the ICD requiring treatment for abuse of or dependence upon substances such as alcohol narcotics or hallucinogens

Non member rate See Covered charges
Non participating A Non participating physician does not have an agreement with the local Blue Shield Plan Payment can be made to the physician or to the member at the Local Plan's option The member is
physician responsible for the balance if any between the Local Plan's payment and the physician's charge

Non participating See Covered charges
Provider Allowance
NPA

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Blue Cross and Blue Shield Service Benefit Plan 2000
Participating A Participating physician is one who at the time a covered service is rendered has a written agreement with the local Blue Shield Plan payment is made to the Participating physician based on
physician a negotiated allowance PAR see Covered charges agreed to between the Participating physician and the Local Plan

Participating See Covered charges
Provider Allowance
PAR

Plan The Blue Cross and Blue Shield Service Benefit Plan
Precertification The requirement to contact the Local Plan serving the area where the services will be rendered before being admitted to a hospital for inpatient care or within two business days following the
admission when the hospital admission is an emergency

Preferred physician A Preferred physician is one who at the time a covered service is rendered has a written agreement with the local Blue Shield Plan payment is made to the Preferred physician based on a negotiated
allowance PPA see Covered charges agreed to between the Preferred physician and the Local Plan

Preferred Provider See Covered charges
Allowance PPA

Preferred provider An arrangement between Local Plans and physicians hospitals health care institutions or other health care professionals or for pharmacies PCS Health Systems Inc to provide services to you at
organization PPO a reduced cost The PPO also known as the Preferred Provider Program PPP provides members
arrangement the opportunity to reduce their out of pocket expenses for care by selecting facilities and providers from among a specific group of health care providers Preferred providers are available in most
locations your use of them whenever possible helps contain health care costs and reduces your outof pocket costs The selection of PPO providers is solely the Local Plan's or for pharmacies PCS

Health Systems Inc responsibility continued participation of any specific PPO provider cannot be guaranteed

Preferred rate See Covered charges
Prior approval Written assurance that benefits will be provided from 1 the Local Plan where the services will be rendered 2 the Retail Pharmacy Program or the Mail Service Prescription Drug Program for
prescription drugs and supplies or 3 the Carrier for the clinical trials benefit for certain organ tissue transplant procedures Home health care home hospice care certain drugs and supplies and certain

organ tissue transplant procedures require prior approval For further information see pages 48 49

Prosthetic appliance A device that is surgically inserted or physically attached to the body to restore a bodily function or replace a physical portion of the body

Routine services Services that are not related to a specific illness injury set of symptoms or maternity care
Sound natural tooth A tooth that is whole or properly restored restoration by amalgams only is without impairment periodontal or other conditions and is not in need of the treatment provided for any reason other
than an accidental injury For purposes of this Plan a tooth with a crown is not considered a sound natural tooth

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Blue Cross and Blue Shield Service Benefit Plan 2000
Section 10 FEHB Facts
You have a right OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right to information about your health plan its networks providers and facilities You can also find
to the following out about care management which includes medical practice guidelines disease management
information programs and how we determine if procedures are experimental or investigational OPM's website www opm gov lists the specific types of information that we must make available to you

If you want specific information about us call or write to us at the telephone number and or address listed on the back of your ID card or visit our website at www fepblue org

Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal Employees Health Benefits Plans brochures for other plans and other material you need to make an
information about informed decision about
enrolling in the When you may change your enrollment
FEHB Program How you can cover your family members What happens when you transfer to another Federal agency go on leave without pay enter

military service or retire
When your enrollment ends and
The next Open Season for enrollment
We don't determine who is eligible for coverage and in most cases cannot change your enrollment status without information from your employing or retirement office

When are my The benefits in this brochure are effective on January 1 If you are new to this plan your coverage and premiums begin on the first day of your first pay period that starts on or after January 1
benefits and Annuitants premiums begin January 1
premiums effective

What happens When you retire you can usually stay in the FEHB Program Generally you must have been enrolled in the FEHB Program for the last five years of your Federal service If you do not meet this
when I retire requirement you may be eligible for other forms of coverage such as Temporary Continuation of Coverage which is described later in this section

What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and your unmarried dependent children under age 22 including any foster or step children your employing or
coverage are retirement office authorizes coverage for Under certain circumstances you may also get coverage
available for me for a disabled child 22 years of age or older who became incapable of self support before age 22
and my family If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry give birth or add a child to your family You may change your enrollment 31 days before to 60 days
after you give birth or add the child to your family The benefits and premiums for your Self and Family enrollment begin on the first day of the pay period in which the child is born or becomes an

eligible family member
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits nor will we Please tell us immediately when you add or remove family

members from your coverage for any reason including divorce
If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled in another FEHB plan

Are my medical and We will keep your medical and claims information confidential Only the following will have access to it
claims records OPM this Plan and our subcontractors when they administer this contract
confidential This plan and appropriate third parties such as other insurance plans and the Office of Workers Compensation Programs OWCP when coordinating benefit payments and

subrogating claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions

OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your identity or

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Blue Cross and Blue Shield Service Benefit Plan 2000
OPM when reviewing a disputed claim or defending litigation about a claim
As part of our administration of prescription drug benefits we may disclose information about your prescription drug utilization including the names of prescribing physicians to any treating

physicians or dispensing pharmacies

Information for
new members Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form

SF 2809 or the OPM annuitant confirmation letter until you receive you ID card You can also use an Employee Express confirmation letter

What if I paid a Your old plan's deductible continues until our coverage begins
deductible under my
old plan

Pre existing We will not refuse to cover the treatment of a condition that you or a family member had before you
conditions enrolled in this Plan solely because you had the condition before you enrolled

When you lose
benefits

What happens if my You will receive an additional 31 days of coverage for no additional premium when
enrollment in this Your enrollment ends unless you cancel your enrollment or
Plan ends You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage

What is former spouse If you are divorced from a Federal employee or annuitant you may not continue to get benefits
coverage under your former spouse's enrollment But you may be eligible for your own FEHB coverage under the spouse equity law If you are recently divorced or are anticipating a divorce contact your

ex spouse's employing or retirement office to get more information about your coverage choices

What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For example you
can receive TCC if you are not able to continue your FEHB enrollment after you retire You may not elect TCC if you are fired from your Federal job due to gross misconduct

Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your
employing or retirement office
Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32 nd day after your regular coverage ends even if several months have passed

You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits

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Blue Cross and Blue Shield Service Benefit Plan 2000
How do I enroll in If you leave Federal service your employing office will notify you of your right to enroll under TCC
TCC You must enroll within 60 days of leaving or receiving this notice whichever is later Children You must notify your employing or retirement office within 60 days after your child is no

longer an eligible family member That office will send you information about enrolling in TCC You must enroll your child within 60 days after they become eligible for TCC or receive this notice
whichever is later
Former spouses You or your former spouse must notify your employing or retirement office within 60 days of one of these qualifying events

Divorce
Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about enrolling in TCC Your former spouse must enroll within 60 days after the event which qualifies them for

coverage or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify your employing or retirement office within the 60 day deadline

How can I convert to You may convert to an individual policy if
individual coverage Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not pay your premium you cannot convert

You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is available You must apply in writing to us within 31 days after you receive this notice However if

you are a family member who is losing coverage the employing or retirement office will not notify you You must apply in writing to us within 31 days after you are no longer eligible for coverage

Your benefits and rates will differ from those under the FEHB Program however you will not have to answer questions about your health and we will not impose a waiting period or limit your
coverage due to pre existing conditions
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that
Certificate of Group indicates how long you have been enrolled with us You can use this certificate when getting health
Health Plan insurance or other health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions
Coverage for health related conditions based on the information in the certificate

If you have been enrolled with us for less than 12 months but were previously enrolled in other FEHB plans you may request a certificate from them as well

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Blue Cross and Blue Shield Service Benefit Plan 2000
Department of Defense FEHB Demonstration Project
What is the The National Defense Authorization Act for 1999 Public law 105 261 established the DoD FEHBP Demonstration Project It allows some active and retired uniformed service members and their
Department of dependents to enroll in the FEHB Program The demonstration will last for three years beginning
Defense DoD and with the 1999 Open Season for the year 2000 Open Season enrollments will be effective January 1 2000 DoD and OPM have set up some special procedures to successfully implement the
FEHB Program Demonstration Project noted below Otherwise the provisions described in this brochure apply
Demonstration
Project

Who is eligible DoD determines who is eligible to enroll in the FEHBP Generally you may enroll if
You are an active or retired uniformed service member and are eligible for Medicare
You are a dependent of an active or retired uniformed service member and are eligible for Medicare

You are a qualified former spouse of an active or retired uniformed service member and you have not remarried or
You are a survivor dependent of a deceased active or retired uniformed service member and
You live in one of the eight geographic demonstration areas
If you are eligible to enroll in a plan under the regular Federal Employees Health Benefits Program you are not eligible to enroll under the DoD FEHBP Demonstration Project

Where are the Dover AFB DE
demonstration Commonwealth of Puerto Rico
areas Fort Knox KY Greensboro Winston Salem High Point NC

Dallas TX
Humboldt County CA area
Naval Hospital Camp Pendleton CA
New Orleans LA

When can I join Your first opportunity to enroll will be during the 1999 Open Season November 8 1999 through December 13 1999 Your coverage will begin January 1 2000 DoD has set up an Information

Processing Center IPC in Iowa to provide you with information about how to enroll IPC staff will verify your eligibility and provide you with FEHB Program information plan brochures enrollment

instructions and forms The toll free phone number for the IPC is 1 877 DOD FEHB 1 877 363 3342

You may select coverage for yourself self only or for you and your family self and family during the 1999 2000 and 2001 Open Seasons Your coverage will begin January 1 of the year following
the Open Season that you enrolled
If you become eligible for the DoD FEHBP Demonstration Project outside of Open Season contact the IPC to find out how to enroll and when your coverage will begin

DoD has a web site devoted to the Demonstration Project You can view information such as their Marketing Beneficiary Education Plan Frequently Asked Questions demonstration area locations
and zip code lists at www tricare osd mil fehbp You can also view information about the demonstration project including The 2000 Guide to Federal Employees Health Benefits Plans
Participating in the DoD FEHBP Demonstration Project on the OPM web site at www opm gov
Am I eligible for See Section 10 FEHB Facts for information about TCC Under this Demonstration Project the only
Temporary individual eligible for TCC is one who ceases to be eligible as a member of family under your self
Continuation of and family enrollment This occurs when a child turns 22 for example or if you divorce and your spouse does not qualify to enroll as an unremarried former spouse under title 10 United States Code
Coverage TCC For these individuals TCC begins the day after their enrollment in the DoD FEHBP Demonstration Project ends TCC enrollment terminates after 36 months or the end of the Demonstration Project

whichever occurs first You your child or another person must notify the IPC when a family member loses eligibility for coverage under the DoD FEHBP Demonstration Project

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Blue Cross and Blue Shield Service Benefit Plan 2000
TCC is not available if you move out of a DoD FEHBP Demonstration Project area you cancel your coverage or your coverage is terminated for any reason TCC is not available when the
demonstration project ends
Do I have the 31 day These provisions do not apply to the DoD FEHBP Demonstration Project
extension and right
to convert

Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for services you did not receive billed you twice for the same service or misrepresented any information do the following

Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 1 800 FEP 8440 and explain the situation
If we do not resolve the issue call or write
THE HEALTH CARE FRAUD HOTLINE 202 418 3300

U S Office of Personnel Management Office of the Inspector General Fraud Hotline
1900 E Street N W Room 6400 Washington DC 20415

Penalties for Fraud
Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud Also the Inspector General may investigate anyone who uses an ID card if they

Try to obtain services for a person who is not an eligible family member or
Are no longer enrolled in the Plan and try to obtain benefits

Your agency may also take administrative action against you

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Blue Cross and Blue Shield Service Benefit Plan 2000
Index
Do not rely on this page it is for your convenience and is not an official statement of benefits
Accidental injury 32 37 50 Freestanding ambulatory facilities 8 9 22 Office visits 27 31 Additional Benefits 31 33 General Exclusions 41 42 Oral and maxillofacial surgery 19 37
Allergy tests 28 29 General health screening 31 Ostomy and catheter supplies 29 Allogeneic bone marrow transplant
Home health care 32 48 53 Other Medical Benefits 26 30 16 18 19 28 Home hospice care 33 48 53 Out of pocket expenses 49 50

Allowable charge 50 51 Home infusion therapy 29 Outpatient accidental injury care 32 Ambulance 29 32 Home nursing care 29 30 Outpatient facility care 26
Anesthesia 16 18 22 50 Home visits 27 Overseas claims 11 35 40 Assignment 50 44 Hospital rooms Oxygen 29
Attending Physician 9 Private 15 21 Pap smear 26 28 31 Autologous bone marrow transplant Semiprivate 15 21 Participating Provider Allowance PAR
16 18 19 28 Immunizations 26 28 31 10 11 51 54 Autologous stem cell support Incubation charges 21 Pharmacotherapy 26 28
16 18 19 28 Independent laboratories 9 28 31 Physical examination 31 Average Wholesale Price AWP Infertility 22 Physical therapy 16 26 28 30 32 33
10 34 49 50 51 Inhospital physician care 16 Physician 9 53 54
Biopsies 17 Inpatient Hospital Benefits 15 17 Pre admission testing 16 Birthing centers 22 Insulin 34 Precertification 6 15 21 24 47 48 54

Blood and blood plasma 16 29 Intensive physician care 16 Preferred Provider Allowance PPA Breast cancer screening 26 28 31
Laboratory and pathological services 10 11 49 51 52 54 Burns 17 16 17 26 28 31 32 Preferred Provider Organization PPO

Carryover 50 Lifetime maximum 8 25 30 53 4 6 54 Casts 16 18 Local Plan 53 Prescription drugs 26 28 29 32 34 35 40
Catastrophic protection 49 50 Machine diagnostic tests Preventive services 26 28 31 Changes for 2000 4 5 16 17 26 28 31 32 Prior approval 19 32 35 48 49 54
Chemotherapy 16 19 26 28 Magnetic Resonance Imagings MRIs Prostate cancer screening 26 28 31 Childbirth 21 23 16 17 26 28 31 32 Prosthetic appliance 29 54
Cholesterol tests 31 Mail Svc Prescription Drug Program 34 35 Psychologist 9 25 Circumcision 21 Mammograms 26 28 31 Psychotherapy 25
Claiming benefits 39 40 Maternity Benefits 21 23 Radiation therapy 16 19 26 28 Coinsurance 7 10 49 50 Maximum Allowable Charge MAC Renal dialysis 26 28
Colorectal cancer screening 26 28 31 36 37 Room and board 15 17 21 Concurrent care 16 50 Medicaid 46
Second surgical opinion 27 Congenital anomalies 17 51 Medically necessary 15 41 53 Skilled nursing facility care 9 33

Consultations 16 Medically underserved areas 10 Smoking cessation 8 30 34 Contraceptive devices and drugs 23 34 Medicare 42 45 Social Worker 10 25
Coordination of benefits 42 47 Medicare Summary Notice 39 44 45 Speech therapy 26 28 30 Covered charges 51 52 Members 53 Splints 16
Covered providers 8 10 Mental Conditions Substance Abuse Standard Option Dental Benefits 36 37 Crutches 29 Benefits 24 25 53 Stem cell transplant support 16 18 19 28
Day night hospital services 25 Merck Medco Rx Services 34 35 Sterilization procedures 17 20 23 Deductible 6 7 Neurological testing 29 Subrogation 45 46
Definitions 50 54 Newborn care 21 31 Substance abuse 8 24 25 53 Dental care 19 29 36 37 41 50 Non FEHB Benefits 38 Surgery 17 20
Diagnostic services 26 28 31 Non participating Provider Allowance Anesthesia 16 18 22 50 Disputed claims review 12 14 NPA 10 49 51 52 Assistant surgeon 15 18
Donor expenses transplants 19 Nurse Multiple procedures 18 Dressings 16 Licensed Practical Nurse 29 Oral 19 37 41
Durable medical equipment 29 33 52 Nurse Anesthetist 18 22 Outpatient 22 27
Effective date of enrollment 52 Nurse Midwife 9 22 28 Reconstructive 20 Emergency admission 15 24 48 Nurse Practitioner 9 Syringes 34

Experimental or investigational 12 Psychiatric Nurse 25 Temporary continuation of coverage 56 57 Explanation of Benefits 39 Registered Nurse 29 Transplants 16 18 19 28 48
Extractions 37 Nursery charges 21 Vision care program 38 Eyeglasses 29 42 Nursing School Administered Clinic 10
Well child care 31 Family deductible 7 Obstetrical care 21 23 Wheelchairs 29

Fecal occult blood test 26 28 31 Occupational therapy 26 28 30 Workers compensation 46 Flexible benefits option 6 Ocular injury 29
X rays 16 17 26 28 31 32 36

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Notes
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Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan
High Option 2000 Do not rely on this chart alone All benefits are subject to the definitions 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 items below
with an asterisk are subject to the 150 per person 300 per family calendar year deductible This Plan has two options a summary of benefits for the Standard Option is located on page 63 of this brochure

Benefits High Option Pays Page
Inpatient Hospital PPO benefit You pay nothing for unlimited days care Non PPO benefit After 100 per admission deductible you pay nothing for unlimited days15

Surgical PPO benefit You pay 5 PPA for physician services Non PPO benefit You pay 20 Allowable charge for physician services 17 20
Medical PPO benefit You pay 5 PPA for physician medical care Non PPO benefit You pay 20 Allowable charge for physician medical care 16
Maternity PPO benefit You pay nothing for physician obstetrical care Non PPO benefit Same benefits as for illness or injury 21 23
Mental Conditions Covered charges up to 120 days per calendar year you pay 20 Allowable charge for inpatient physician care
PPO benefit You pay up to 75 per day for the first 120 days you pay all charges thereafter Non PPO benefit You pay up to 150 per day in Member hospitals and up to 300
per day in Non member hospitals for the first 120 days per calendar year you pay all
charges thereafter 24
Substance Abuse One treatment program 28 day maximum per lifetime 25
Outpatient Hospital PPO benefit You pay up to 10 per day in connection with outpatient surgery you care pay up to 10 per day for other outpatient care not related to outpatient surgery or

accidental injury care Non PPO benefit You pay up to 50 per day at Member facilities and up to 100 per
day at Non member facilities in connection with outpatient surgery you pay up to 50 per day at Member facilities and up to 100 per day at Non member facilities for
other outpatient care not related to outpatient surgery or accidental injury care 26 27 32
Surgical PPO benefit You pay 5 PPA for physician services Non PPO benefit You pay 20 Allowable charge for physician services 17 20

Medical PPO benefit You pay a 12 copayment per covered visit Non PPO benefit For home and office visits you pay 20 Allowable charge 27 28
Maternity PPO benefit You pay nothing for physician obstetrical care Non PPO benefit Same benefits as for illness or injury 21 23
Home Health Care You pay nothing for home health care agency charges up to 90 days per calendar year Also see page 29 for Home nursing care benefit 32
Mental PPO benefit You pay up to 10 per day at Preferred facilities for outpatient facility care Conditions Non PPO benefit You pay up to 50 per day at Member facilities and up to 100 per
Substance Abuse day at Non member facilities for outpatient facility care you pay 30 Allowable charge for outpatient professional care for mental conditions substance abuse up to 50 visits per
calendar year 25
Emergency care Outpatient You pay nothing for hospital and physician services rendered within 72 hours of injury 32 accidental injury care

Prescription drugs PPO benefit Retail Pharmacy Program You pay 15 PPA 34
Non PPO benefit Retail Pharmacy Program You pay 35 Average Wholesale Price AWP 34

Mail Service Prescription Drug Program You pay an 8 generic and 14 brand name per prescription copay 35
Dental care Dental services required due to accidental injury and covered oral and maxillofacial surgery 19 29
Additional benefits Preventive services provided by PPO providers Home hospice care Well child care and Skilled nursing facility care 31 33
Protection against You pay nothing for Covered charges when applicable coinsurance and deductibles reach catastrophic costs 1,000 per contract in a calendar year when PPO providers are used and
2,700 when they are not 49

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62 Page 63 64
Summary of Benefits for the Blue Cross and Blue Shield Service Benefit Plan
Standard Option 2000 Do not rely on this chart alone All benefits are subject to the definitions 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 items below
with an asterisk are subject to the 200 per person 400 per family calendar year deductible This Plan has two options a summary of benefits for the High Option is located on page 62 of this brochure

Benefits Standard Option Pays Page
Inpatient Hospital PPO benefit You pay nothing for unlimited days care Non PPO benefit After 250 per admission deductible you pay nothing for unlimited days 15

Surgical PPO benefit You pay 10 PPA for physician services Non PPO benefit You pay 25 Allowable charge for physician services 17 20
Medical PPO benefit You pay 10 PPA for physician medical care Non PPO benefit You pay 25 Allowable charge for physician medical care 16
Maternity PPO benefit You pay nothing for physician obstetrical care Non PPO benefit Same benefits as for illness or injury 21 23
Mental Conditions Covered charges up to 100 days per calendar year you pay 40 Allowable charge for inpatient physician care
PPO benefit You pay up to 150 per day for the first 100 days you pay all charges thereafter
Non PPO benefit You pay up to 250 per day in Member hospitals and up to 400 per day in Non member hospitals for the first 100 days per calendar year you pay all charges
thereafter .24
Substance Abuse One treatment program 28 day maximum per lifetime 25
Outpatient Hospital PPO benefit You pay up to 25 per day in connection with outpatient surgery you care pay up to 25 per day for other outpatient care not related to outpatient surgery or

accidental injury care Non PPO benefit You pay up to 100 per day at Member facilities and up to 150
per day at Non member facilities in connection with outpatient surgery you pay up to 100 per day at Member facilities and up to 150 per day at Non member facilities
for other outpatient care not related to outpatient surgery or accidental injury care 26 27 32
Surgical PPO benefit You pay 10 PPA for physician services Non PPO benefit You pay 25 Allowable charge for physician services 17 20

Medical PPO benefit You pay a 12 copayment per covered visit Non PPO benefit You pay 25 Allowable charge for home and office visits 27 28
Maternity PPO benefit You pay nothing for physician obstetrical care Non PPO benefit Same benefits as for illness or injury 21 23
Home Health Care No current Home health care benefit See page 29 for Home nursing care benefit 32
Mental PPO benefit You pay up to 25 per day at Preferred facilities for outpatient facility care Conditions Non PPO benefit You pay up to 100 per day at Member facilities and up to 150 per

Substance Abuse day at Non member facilities for outpatient facility care you pay 40 Allowable charge for outpatient professional care for mental conditions substance abuse up to 25 visits per
calendar year 25
Emergency care Outpatient You pay nothing for hospital and physician services rendered within 72 hours of injury 32 accidental injury care

Prescription drugs PPO benefit Retail Pharmacy Program You pay 25 PPA 34
Non PPO benefit Retail Pharmacy Program You pay 45 Average Wholesale Price AWP 34

Mail Service Prescription Drug Program You pay a 12 generic and 20 brand name per prescription copay 35
Dental care Fee schedule allowances for diagnostic and preventive services fillings and extractions Higher level fee schedule allowances for children up to age 13 dental services required
due to accidental injury and covered oral and maxillofacial surgery 19 29 36 37
Additional benefits Preventive services provided by PPO providers Home hospice care Well child care and Skilled nursing facility care 31 33

Protection against You pay nothing for Covered charges when applicable coinsurance and deductibles reach catastrophic costs 2,000 per contract in a calendar year when PPO providers are used and
3,750 when they are not 49

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2000 Rate Information for
Blue Cross and Blue Shield Service Benefit Plan

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 In 2000 two categories of contribution rates referred to as
Category A rates and Category B rates will apply for certain career employees If you are a career employee who is not a member
of a special postal employment class refer to the category definitions in The Guide to Federal Employees Health Benefits Plans
for United States Postal Service Employees RE 70 2 to determine which rate applies to you

Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes or associate
members of any postal employee organization Such persons not subject to postal rates must refer to the applicable Guide to
Federal Employees Health Benefits Plans

Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly

Type of Gov't Your Gov't Your USPS Your USPS Your
Enrollment Code Share Share Share Share Share Share Share Share

High Option
Self Only 101 78.83 66.29 170.80 143.63 93.06 52.06 93.26 51.86

High Option
Self and 102 175.97 134.35 381.27 291.09 207.74 102.58 201.02 109.30
Family

Standard
Option 104 78.83 30.04 170.80 65.09 93.06 15.81 93.26 15.61
Self Only

Standard
Option 105 175.97 66.78 381.27 144.69 207.74 35.01 201.02 41.73
Self and
Family

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