Pages 1--36 from 1998 Bro RI 71-9 pg19 opt

A Managed Fee for Service Plan
with a Preferred Provider Organization

For changesin 4
Sponsored and administered by the National Association of Letter Carriers AFL CIO
benefitssee page

Who may enroll in this Plan All Federal and Postal Service employees and annuitants
who are eligible to enroll in the FEHB Program may become members of this Plan To enroll you must be
or must become a member of the National Association of Letter Carriers

To become a member or associate member All active Postal Service employees must be dues paying
members of an NALC local Enter the number of your local immediately after the name of this Plan in Item
1 of Part B of your registration form

If you are a non postal employee annuitant you will automatically become an associate member of NALC
upon enrollment in the NALC Health Benefit Plan

Annuitants retirees may enroll in this Plan
Membership dues 36 per year for an associate membership New associate members will be billed for
annual dues when the Plan receives notice of enrollment Continuing associate members will be billed by
NALC for the annual membership Active and retired Postal Service employees membership dues vary by
NALC local

Enrollment code for this Plan
321 Self Only
322 Self and Family

Visit the OPM website at httpwwwopmgovinsure
and
Visit the NALC Health Benefit Plan website at httpwwwnalcorghbp

Authorized for distribution by the
United States Office of
Personnel Management Federal Employees
Retirement and Insurance Health Benefits Program

RI 71 9 1
1 Page 2 3
NALC Health Benefit Plan 2000
Table of Contents

Introduction 3
Plain language 3
How to use this brochure 3
Section 1 Fee For Service Plans 3
Section 2 How we change for 2000 4
Section 3 How to get benefits 4
Section 4 What if we deny your claim or request for coverage or pre authorization 8
Section 5 BENEFITS 10
Section 6 How to file a claim 21
Section 7 General exclusions Things we don't cover 22
Section 8 Limitations Rules that affect your benefits 23
Section 9 Fee for Service Facts 26
Section 10 FEHB FACTS 30
Department of Defense FEHB Demonstration Project 32
Inspector General Advisory Stop Health Care Fraud 33
Index 34
Summary of benefits Inside back cover 35
Premiums Back cover 36

2 2
2 Page 3 4
NALC Health Benefit Plan 2000
Introduction
NALC Health Benefit Plan 20547 Waverly Court
Ashburn VA 20149 0001
This brochure describes the benefits you can receive from The NALC Health Benefit Plan under its contract CS1067 with the Office of Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law

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 page 4 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 NALC Health 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 coverage or 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 coverage or pre authorization
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 things that we will not cover
8 Limitations Rules that affect your benefits This section describes limits that can affect your benefits such as Medicare other group insurance and third party liability
9 Fee for Service Facts This section contains information about pre certification protection against catastrophic expenses and a definition section
10 FEHB FACTS Read this for information about the Federal Employees Health Benefits FEHB Program

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 plans reimburse 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 varies 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 with The First Health Network This arrangement with health care providers gives you enhanced benefits or limits your out of pocket expenses

3 3
3 Page 4 5
NALC Health Benefit Plan 2000
Section 2 How we change for 2000
Program wide This year you have a right to more information about this Plan care management our networks changes 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 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 will cover a screening sigmoidoscopy every five years This screening is for colorectal cancer
Three states are added to the list of medically underserved areas they are Kentucky Missouri and Utah
Changes to this Your share of the NALC Postal A premium will increase by 8.0 for Self Only or 3.2 for Plan Self and Family

Your share of the NALC Postal B premium will increase by 7.3 for Self Only or 7.5 for Self and Family Your share of the NALC non Postal premium will increase by 8.6 for Self Only or 8.0 for Self and
Family The Plan's rate of reimbursement for PPO providers for inpatient professional care and outpatient
hospital and medical care is increased to 85 of the negotiated rate from 80 Member copayments for routine services by a PPO provider listed on page 16 now range from 5 to
25 per service The member's copayment for each allergy injection by a PPO provider is now 5
A toll free 24 hour nurse health resource line is available 7 days a week to answer your health care concerns Arrangements for discounted rates for your purchase or rental of durable medical equipment DME
are available Contact the Plan immediately when DME is prescribed Member copayments for PPO providers are not counted toward your out of pocket expenses limit
under the catastrophic protection provision Prior Plan authorization is required for the purchase of certain drugs The Plan may limit the maximum
dosage dispensed by protocols set by the Plan

Section 3 How to get benefits
How do I keep my health care

expenses down
You can help FEHB plans are expected to manage their costs prudently All FEHB plans have cost containment measures in place All fee for service plans include two specific provisions in their benefits packages

precertification of all inpatient admissions and the flexible benefits option Some include managed care options such as 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 You or
your doctor must check with your Plan before being admitted to the hospital If that doesn't happen your Plan will reduce benefits by 500 Be a responsible consumer Be aware of your Plan's cost containment
provisions You can avoid penalties and help keep premiums under control by following the procedures specified on page 26 of this brochure

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

4 4
4 Page 5 6
NALC Health Benefit Plan 2000
Section 3 How to get benefits continued
PPO This Plan offers most of its members the opportunity to reduce out of pocket expenses by choosing providers who participate in the Plan's preferred provider organization PPO Consider the PPO cost
savings when you review Plan benefits and check with the Carrier to see whether PPO providers are available in your area

How much do I You must share the cost of some services These cost sharing measures include deductibles pay for services coinsurance and copayments These and other measures are described in more detail below
Deductibles A deductible is the amount of expense an individual must incur for covered services and supplies before the Plan starts paying benefits for the expense involved A deductible is not reimbursable by the Plan and
benefits paid by the Plan do not count toward 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 covered expenses an individual must incur each calendar year before the Plan pays certain benefits The separate calendar year deductibles apply as follows Other Medical
Benefits 275 Inpatient services under Substance Abuse Benefits 250 inpatient and outpatient professional services under Mental Conditions Substance Abuse Benefits 250 and Retail pharmacy 25

Each of these deductibles applies to each individual once during a calendar year regardless of how many illnesses or injuries the person may have Only those expenses covered under each provision may be
applied toward that deductible Charges in excess of the reasonable and customary fee incurred while not enrolled in this Plan or considered under other benefit provisions unless specifically listed do not count
toward the deductibles
Hospital There is a 100 deductible per inpatient hospital medical surgical or maternity admission and a 500 deductible admission per inpatient mental conditions admission However if a PPO hospital is used the medical per admission

deductible is waived and the deductible for inpatient mental conditions admissions is 400 see page 14
Carryover If you changed to this Plan during open season from a plan with a deductible and the effective date of the change was after January 1 any expenses that would have applied to that plan's deductible in the prior year

will be covered by your old plan if they are for care you got in January before the effective date of your coverage in this Plan If you have already met the deductible in full your old plan will reimburse these
covered expenses If you have not met it in full your old plan will first apply your covered expenses to satisfy the rest of the deductible and then reimburse you for any additional covered expenses The old plan
will pay these covered expenses according to this year's benefits benefit changes are effective on January 1
Family limit Under family enrollment the Other Medical Benefits deductible and the retail pharmacy deductible are considered satisfied and benefits are payable for all family members when the combined covered expenses

applied to the deductible reach 550 Other Medical Benefits and 50 retail pharmacy in a calendar year
Coinsurance Coinsurance is the stated percentage of covered charges you must pay after you have met any applicable deductible The Plan will base this percentage on either the billed charge or the usual reasonable and

customary charge whichever is less For instance under Other Medical Benefits when the Plan pays 70 of reasonable and customary charges for a covered service you are responsible for 30 of the reasonable
and customary charges i e the coinsurance In addition you may be responsible for any excess charge over the Plan's reasonable and customary allowance For example if the provider ordinarily charges 100
for a service but the Plan's reasonable and customary allowance is 95 the Plan will pay 70 of the allowance 66.50 You must pay the 30 coinsurance 28.50 plus the difference between the actual
charge and the reasonable and customary allowance 5 for a total member responsibility of 33.50 Remember under Other Medical Benefits services and supplies by a PPO provider will be payable at 85
of negotiated rates and if surgery is performed by a PPO doctor benefits are payable at 85 of negotiated rates not 70 as for non PPO doctors

When hospital When inpatient claims are paid according to a Diagnostic Related Group DRG limit for instance for admissions charges are of certain retirees who do not have Medicare see page 26 the Plan will pay 30 of the total covered amount
limited by law as room and board charges and 70 as other charges and will apply your coinsurance accordingly
Copayments A copayment is the stated amount the Plan requires you to pay for certain covered services such as 12 per prescription for generic mail order drugs or 15 per office visit at a PPO provider

If provider If a provider routinely waives does not require you to pay your share of the charge for services waives your rendered the Plan is not obligated to pay the full percentage of the amount of the provider's original charge
share 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 30 coinsurance the actual charge is 70 The Plan will pay 49 70 of
the actual charge of 70

5 5
5 Page 6 7
NALC Health Benefit Plan 2000
Section 3 How to get benefits continued
Lifetime Substance abuse benefits are limited to a lifetime maximum per person of 30 days room and board maximums and ancillary charges in a treatment facility Hospice care benefits are limited to a lifetime maximum of

3,000 and Smoking cessation benefits are limited to a lifetime maximum of 100
Do I have to You usually do not have to submit claims to us if you use preferred providers If you file a claim submit claims please send us all of the documents for your claim as soon as possible Claims must be received by us

within two years of the date of 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 In a Fee for Service Plan you may choose any covered facility or provider my health care

Covered facilities
Birthing A free standing facility that provides comprehensive maternity care in a home like atmosphere and is center licensed or certified by the jurisdiction

Hospice A facility that 1 provides care to the terminally ill 2 is licensed certified by the jurisdiction in which it operates 3 is supervised by a staff of doctors M D or D O with at least one such doctor on call 24 hours
a day 4 provides 24 hour a day nursing services under the direction of a registered nurse R N and has a full time administrator and 5 provides an ongoing quality assurance program

Hospital An institution that 1 is accredited as a hospital under the hospital accreditation program of the Joint Commission on Accreditation of Healthcare Organizations or 2 any other institution that is licensed as a
hospital under the supervision of a staff of doctors and with 24 hour a day registered nursing service and that is primarily engaged in providing general inpatient acute care and treatment of sick and injured persons

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

In no event shall the term hospital include a convalescent home or extended care facility or any institution or part thereof which a is used principally as a convalescent facility nursing home or facility for the
aged b furnishes primarily domiciliary or custodial care including training in the routines of daily living or c is operated as a school or residential treatment facility

Skilled nursing A facility licensed or certified by the State or eligible for payment under Medicare that provides facility SNF continuous non custodial inpatient skilled nursing care by an organized medical staff for post hospital
patients
Treatment A freestanding institution separately licensed by the jurisdiction for rehabilitative treatment of facility alcoholism or drug abuse on its premises 24 hours a day and that maintains a course of treatment based on

the patient's individual needs
Covered providers For purposes of this Plan covered providers include
1 A licensed doctor of medicine M D or osteopathy D O or for specified services covered by the Plan a licensed dentist D D S or D M D or podiatrist D P M practicing within the scope of their license

2 A nurse anesthetist CRNA 3 A community mental health organization A nonprofit organization or agency with a governing or
advisory board representative of the community that provides comprehensive consultative and emergency services for treatment of mental conditions
4 Other providers listed with the benefits sections 5 Other covered providers include a qualified clinical psychologist clinical social worker optometrist
nurse midwife nurse practitioner clinical specialist and nursing school administered clinic For purposes of this FEHB brochure the term doctor includes all of these providers when the services
are performed within the scope of their license or certification
Coverage in 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

underserved the States designated as medically underserved are Alabama Idaho Kentucky Louisiana Mississippi areas Missouri New Mexico North Dakota South Carolina South Dakota Utah and Wyoming

PPO arrangements Benefits under this Plan are available from facilities such as hospitals and from providers such as doctors and other health care personnel who provide covered services This Plan covers two types of facilities and
providers 1 those who participate in a preferred provider organization PPO and 2 those who do not Who these health care providers are and how benefits are paid for their services are explained below In
general it works like this
6 6
6 Page 7 8
NALC Health Benefit Plan 2000
Section 3 How to get benefits continued
PPO facilities and providers have agreed to provide services to Plan members at a lower cost than you'd usually pay a non PPO provider Although PPOs are not available in all locations or for all services when
you use these providers you help contain health care costs and reduce what you pay out of pocket The selection of PPO providers is solely the Carrier's responsibility continued participation of any specific
provider cannot be guaranteed While PPO providers agree with the Carrier to provide covered services final decisions about health care are the sole responsibility of the doctor and patient and are independent of
the terms of the insurance contract
PPO benefits apply only when you use a PPO provider Provider networks may be more extensive in some areas than others The availability of every speciality in all areas cannot be guaranteed If no PPO provider

is available or you do not use a PPO provider the standard non PPO benefits apply
When you use a PPO hospital keep in mind that the professionals who provide services to you in the hospital such as emergency room physicians radiologists anesthetists and pathologists may not all be

preferred providers If they are not they will be paid by this Plan as non PPO providers
Non PPO facilities and providers do not have special agreements with the Plan The Plan makes its regular payments toward the bills and you're responsible for any balance

This Plan's PPO The Plan offers you a broad national PPO network If you choose a PPO provider then you will be eligible for the enhanced PPO benefit levels described below Please understand that PPO providers may
not be available in all geographic regions particularly in Maine and Maryland due to state laws affecting provider contracting Maryland has no hospital network and Maine has no hospital network and no
physician outpatient care network Information on PPO providers in specific regions is available through the Plan's toll free provider locator service 1 800 622 6252 website http www nalc org hbp or PPO
directories In areas where a PPO provider is unavailable members can choose a non PPO provider and receive standard non PPO benefits under the Plan

When a PPO hospital is used the 100 per admission deductible and the 20 coinsurance are waived for medical surgical and maternity confinements other hospital charges are covered at 100 and the per
admission deductible for mental conditions confinements is 400 When you choose a PPO provider the Plan pays 100 of the negotiated rate after you pay a copayment per service such as allergy injection 5
office visit 15 and specific routine services from 5 to 25 as listed on page 16 Other services by PPO doctors and health care professionals are paid at 85 of the negotiated rate under Other Medical Benefits
after satisfaction of the 275 calendar year deductible
When admitted to a PPO network hospital show your NALC identification card to the admissions department and advise them that NALC participates in the PPO program Also make an assignment of benefits to

the hospital The hospital will then file the claim on your behalf Benefits will be paid to the hospital Enrollees residing in a PPO region will receive a listing of the PPO hospitals and health care institutions
in their service area Contact the Plan at 1 800 548 8454 for information or to obtain a list of PPO hospitals in your area

Follow the same procedures when visiting a PPO doctor The doctor and other health care professional networks are generally in the same geographic areas as the hospitals For information on general practitioners
and specialists in those areas call 1 800 622 6252 The Plan is solely responsible for the selection of PPO providers and any questions regarding PPO providers should be directed to the Plan When you phone
for an appointment please remember to verify that the physician is still a PPO provider
What do I do if First call our customer service department at 703 729 4677 If you are new to the FEHB Program we will I'm in the reimburse your covered expenses If you are currently in the FEHB Program and are switching to us your

hospital when I former plan will pay for the hospital stay until join this Plan
You are discharged not merely moved to an alternative care center or You exhaust the benefits available from your former plan or

The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
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 continue seeing serious illness and your provider for up to 90 days after you receive notice that we are terminating our contract with the provider

my provider leaves unless the termination is for cause If you are in the second or third trimester of pregnancy you may the Plan or this continue to see your OB GYN until the end of your postpartum care
Plan leaves the You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and Program
you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic condition or are in your 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
7 7
7 Page 8 9
NALC Health Benefit Plan 2000
Section 3 How to get benefits continued
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 you decide Our Medical Director reviews current medical resources to determine if a service or supply is experimental if a service is or investigational An independent expert opinion may be sought by us if necessary
experimental or investigational

Experimental or A drug device or biological product is experimental or investigational if the drug device or biological product investigational 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 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
If you wish to obtain information concerning the experimental investigational determination process please contact the Plan

Section 4 What to do if we deny your claim or request for coverage or 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 before filing a the claim was filed correctly For instance did the provider use the correct procedure code for the services
disputed claim performed surgery laboratory test x ray office visit etc Have your 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 coverage or 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 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

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

a denial service
What if I have a Call us at 703 729 4677 and we will expedite our review serious or life
threatening condition and you
haven't responded to my request for
coverage or pre authorization

8 8
8 Page 9 10
NALC Health Benefit Plan 2000
Section 4 What to do if we deny your claim or request for coverage or pre authorization continued
What if you have If we expedite your review due to a serious medical condition and deny your claim we will inform OPM so denied my request that they can give your claim expedited treatment too Alternatively you can call OPM's health benefits
for care and my Contract Division II at 202 606 3818 between 8 a m and 5 p m Eastern time Serious or life threatening condition is serious conditions are ones that may cause permanent loss of bodily functions or death if they are not treated as
or life threatening soon as possible
Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our time limits initial denial 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 Your request must be complete or OPM will return it to you You must send the following to OPM information
1 A statement about why you believe our decision is wrong based on specific 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 Those who have a legal right to file a disputed claim with OPM are the 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

Where should I mail Send your request for review to Office of Personnel Management Office of Insurance Programs my disputed claim Contracts Division II P O Box 436 Washington D C 20044
to OPM
What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our decision upholds the your only recourse is to sue

Plan's denial 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 Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its if I 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 as

established at section 890.105 title 5 Code of Federal Regulations CFR As required by section 890.107 title 5 CFR such a lawsuit must be brought against the Office of Personnel Management in
Federal court
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

9 9
9 Page 10 11
NALC Health Benefit Plan 2000
Section 5 BENEFITS Inpatient Hospital Benefits
All benefits are subject to definitions limitations and exclusions in this brochure and are payable when determined by us to be medically necessary

What is covered The Plan pays for inpatient hospital services as shown below
Precertification The medical necessity of your hospital admission must be precertified for you to receive full Plan benefits Emergency admissions not precertified must be reported within two business days following the day of

admission even if you have been discharged Otherwise the benefits payable will be reduced by 500 See page 26 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 and Puerto
Rico For information on when Medicare is primary see pages 23 24
Room and board Plan pays for ward semiprivate or intensive care accommodations including general nursing care meals and special diets furnished by a hospital for an inpatient Charges for a private room will be covered only

when the patient's isolation is required by law or the Plan determines that isolation is required to prevent contagion If for any other reason a private room is used the Plan will pay the hospital's average charge
for semiprivate accommodations If the hospital has private accommodations only the average semiprivate rate is determined on the basis of the charges of the most comparable hospital in the area

PPO Plan pays room and board at 100 with no deductible when admission is to a PPO hospital See page 6 benefit
Non PPO After a 100 deductible per admission Plan pays room and board at 80 benefit
Flat rate hospital charges for non PPO hospitals are prorated 30 room and board and 70 other charges Other prorations may apply to PPO hospitals for which rates are negotiated See page 5 When hospital

charges are limited by law
Other charges Plan pays for other covered inpatient services and supplies as shown below
Professional ambulance service to the nearest hospital equipped to handle the patient's condition Anesthetics and oxygen including nurse anesthetist services

X ray and laboratory tests Blood or blood plasma if not donated or replaced
Internal prostheses including an internal breast prosthesis following a mastectomy Drugs and medicines
Additional ancillary services such as operating recovery and treatment rooms equipment and dressings splints and casts

PPO Plan pays Other charges at 100 when admission is to a PPO hospital See page 6 benefit
Non PPO Plan pays Other charges at 80 benefit

Limited benefits
Pre admission Plan pays for pre admission testing within 7 days of admission or outpatient surgery Covered screening testing tests include chest X rays electrocardiograms urinalyses and blood work but do not include diagnostic

tests such as magnetic resonance imaging throat cultures or similar studies
PPO Plan pays for pre admission testing at 100 when provided by a PPO hospital See page 6 benefit

Non PPO Plan pays for pre admission testing at 80 benefit
Hospitalization for Plan pays benefits for hospitalization for dental procedures only when a nondental physical impairment dental work and exists which makes hospitalization necessary to safeguard the health of the patient Hospital benefits
foot treatment for inpatient foot treatment are payable even if no other benefits are payable
Related benefits
Professional Doctors inpatient medical visits are covered under Other Medical Benefits For inpatient services charges by anesthesiologists radiologists and pathologists

PPO Plan pays 85 of negotiated rate See page 6 benefit
Non PPO Plan pays 70 of the reasonable and customary charge benefit

10 10
10 Page 11 12
NALC Health Benefit Plan 2000
Section 5 BENEFITS Inpatient Hospital Benefits continued
Take home Medical supplies appliances medical equipment and any covered items billed by a hospital for use at items home are covered only under Other Medical Benefits
What is not covered Room and board and doctor care when in the Carrier's judgment an admission or portion thereof is not medically necessary i e the medical services did not require the acute care setting but could have
been provided in a doctor's office hospital outpatient department skilled nursing facility or other setting without adversely affecting the patient's condition or the quality of medical care rendered In this
event the Carrier will pay benefits for services and supplies other than room and board and in hospital physician care at the level at which they would have been covered if provided in an alternative setting
Room and board in institutions which do not meet the definition of Covered facilities on page 6 such as nursing homes extended care facilities schools residential treatment centers halfway houses or which
have as their primary purpose the furnishing of food shelter training or non medical personal services
Personal comfort items such as telephone television barber services guest meals and beds
Surcharges made by hospitals
Private duty nursing care while confined in a hospital
Custodial care as defined on page 28

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

Section 5 BENEFITS Surgical Benefits
What is covered The Plan pays for the following services
Hospital inpatient Surgeons charges including procedures for sterilization and gastric bypass for morbid obesity outpatient

PPO If the surgery is performed by a Plan PPO network doctor benefits for the inpatient or outpatient surgical benefit procedure will be payable at 85 of the surgeon's negotiated rate after satisfaction of the 275 calendar
year deductible see page 5
Non PPO If the surgery is not performed by a Plan PPO network doctor benefits for the inpatient or outpatient benefit surgical procedure will be payable at 70 of the reasonable and customary charge after satisfaction of the

275 calendar year deductible
Multiple surgical When multiple or bilateral surgical procedures that add time or complexity to patient care are performed procedures during the same operative session the Plan will consider as an eligible expense the reasonable and customary

charge for the first or major procedure in full plus one half the reasonable and customary value of the second or lesser procedure s

Incidental When an incidental procedure e g appendectomy lysis of adhesion puncture of ovarian cyst is procedures performed through the same incision the benefit shall be that of the major procedure only Separate
benefits will not be provided for procedures deemed by the Plan to be incidental to the total surgery
Assistant surgeon For assistant surgeons fees the Plan will consider up to 25 of the reasonable and customary inpatient surgical charge as a covered expense

outpatient
Second opinion Charges for a second surgical opinion are considered under Other Medical Benefits voluntary

Related benefits
Professional Inpatient see Professional charges on page 10 charges Outpatient services by anesthesiologists radiologists and pathologists

PPO Plan pays 85 of negotiated rate after satisfaction of the 275 calendar year deductible benefit
Non PPO Plan pays 70 of the reasonable and customary charge after satisfaction of the 275 calendar year deductible benefit
Organ tissue transplants and
donor expenses
What is The following human organ tissue transplant procedures are covered subject to the conditions and covered limitations below

Bone cornea heart heart lung kidney liver pancreas and kidney pancreas Single or double lung transplants limited to patients for the following end stage pulmonary diseases

11 11
11 Page 12 13
NALC Health Benefit Plan 2000
Section 5 BENEFITS Surgical Benefits continued
primary fibrosis primary pulmonary hypertension or emphysema double lung transplants limited to patients with cystic fibrosis

Bone marrow transplants and stem cell support as follows
Allogeneic bone marrow transplants limited to patients with acute leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma advanced neuroblastoma aplastic anemia chronic

myelogenous leukemia infantile malignant osteoporosis severe combined immunodeficiency thalassemia major or Wiskott Aldrich syndrome
Autologous bone marrow transplants autologous stem cell support and autologous peripheral stem cell support for acute lymphocytic or non lymphocytic leukemia advanced Hodgkin's lymphoma
advanced non Hodgkin's lymphoma advanced neuroblastoma breast cancer multiple myeloma epithelial ovarian cancer and testicular mediastinal retroperitoneal and ovarian germ cell tumors

Related medical and hospital expenses of the donor are covered when the recipient is covered by the Plan Recipient means an insured person who undergoes an operation to receive an organ transplant Donor
means a person who undergoes an operation for the purpose of donating an organ for transplant surgery
National The Plan participates in The First Health National Transplant Program Before your initial transplant evaluation as a potential candidate for a transplant procedure you or your doctor must contact

program First Health at 1 800 622 6252 and ask to speak to a Transplant Case Manager You will be given information about this program including a list of participating providers

The reasonable and customary charges for services performed by a National Transplant Program provider whether incurred by the recipient or donor are paid at 100 Participants in the program must receive prior
approval from the Plan for travel and lodging costs
Limited If prior approval is not obtained or a designated facility is not used pretransplant evaluation organ benefits procurement inpatient hospital surgical and medical expenses for covered transplants whether incurred by

the recipient or donor are limited to a maximum of 100,000 for each listed transplant kidney limit 50,000
What is not Donor screening tests for organ transplants except those performed for the actual donor covered Implants of artificial organs

Transplants not listed as covered
Oral and The following oral surgical procedures are covered maxillofacial
Reduction of fractures of the jaws or facial bones surgery Surgical correction of cleft lip cleft palate or severe functional malocclusion

Removal of stones from salivary ducts Excision of leukoplakia or malignancies
Excision of cysts and incision of abscesses when done as independent procedures Other surgical procedures that do not involve the teeth or their supporting structures

Mastectomy Benefits will be provided for breast reconstruction surgery following a mastectomy including surgery 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

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
Screening The Plan covers one routine screening sigmoidoscopy every 5 years starting at age 50 sigmoidoscopy
What is not Oral implants and transplants covered Procedures that involve the teeth or their supporting structures such as the periodontal membrane
gingiva and alveolar bone Voluntary reversal of surgical sterilization
Cutting trimming or removal of corns calluses or the free edge of toenails and similar routine treatment of conditions of the foot except when necessary because the individual is under active
treatment for a metabolic or peripheral vascular disease Radial keratotomy and other refractive surgery
Cosmetic surgery see definition on page 28 except for repair of accidental injury if repair is initiated within six months after an accident to correct a congenital anomaly of a child born under the Program
and for breast reconstruction following a mastectomy Standby physicians and surgeons except during angioplasty or other high risk procedures when the

Plan determines standbys are medically necessary
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

12 12
12 Page 13 14
NALC Health Benefit Plan 2000
Section 5 BENEFITS Maternity Benefits
What is covered The Plan pays the same benefits for hospital surgery delivery laboratory tests and other medical expenses as for illness or injury The mother at her option may remain in the hospital up to 48 hours after a regular
delivery and 96 hours after a caesarean delivery Inpatient stays will be extended if medically necessary Inpatient hospital

Precertification Precertification is not required for maternity admissions for routine deliveries However if your medical condition requires that you stay more than 48 hours after a regular delivery or 96 hours after a cesarean
section you your physician or the hospital must contact the Plan for certification of the additional days If the certification for additional days is not obtained and a retrospective medical review determines the
additional days were not medically necessary the Plan will not pay for charges incurred on those noncertified days If certification is not obtained but the benefits are otherwise payable benefits for the
admission will be reduced by 500 Newborn confinements that extend beyond the mother's discharge must also be precertified If any of the above are not done the benefits payable will be reduced by 500
See page 26 for details
Room and Plan pays for ward semiprivate or intensive care accommodations including general nursing care meals board and special diets furnished by a hospital for an inpatient

PPO Plan pays room and board at 100 with no deductible when admission is to a PPO hospital benefit See page 6
Non PPO After a 100 deductible per admission Plan pays room and board at 80 benefit
Flat rate hospital charges for non PPO hospitals are prorated 30 room and board and 70 other charges Other prorations may apply to PPO hospitals for which rates are negotiated See page 5 When hospital

charges are limited by law
Other charges Plan pays for other covered hospital services and supplies See Inpatient Hospital Benefits
PPO Plan pays Other charges at 100 when admission is to a PPO hospital See page 6 benefit

Non PPO Plan pays Other charges at 80 benefit
Ordinary bassinet or nursery charges on days when the mother would normally be confined after delivery are considered hospital expenses of the mother Other expenses of the child will be considered the child's

own and will be payable only if the child is covered under a Self and Family enrollment and if the confinement is for the treatment of illness or injury of the child

Outpatient care The Plan pays the same benefits as listed above for admission to a birthing center
Obstetrical care Plan pays delivery fees including prenatal and postpartum care and services of doctors and nurse midwives
PPO If the delivery is performed by a Plan PPO network provider the benefit for delivery will be payable benefit at 85 of the negotiated rate after satisfaction of the 275 calendar year deductible see page 6

Non PPO If the delivery is performed by a non PPO provider the benefit for delivery will be payable at benefit 70 of the reasonable and customary charge after satisfaction of the 275 calendar year deductible
Related benefits
Diagnosis and Diagnostic testing and treatment of infertility except as excluded below are covered under Other treatment of Medical Benefits

infertility
Testing Group B streptococcus infection screening of pregnant women sonograms fetal monitoring and other related tests medically indicated for the unborn child are covered under Other Medical Benefits Amniocentesis

is covered under Surgical Benefits
Voluntary See Surgical Benefits sterilization

For whom Benefits are payable under Self Only enrollments and for family members under Self and Family enrollments
What is not Routine sonograms to determine fetal age size or sex covered Assisted Reproductive Technology ART procedures such as artificial insemination in vitro fertilization

embryo transfer and GIFT as well as services and supplies related to ART procedures are not covered Genetic counseling

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

13 13
13 Page 14 15
NALC Health Benefit Plan 2000
Section 5 BENEFITS Mental Conditions Substance Abuse Benefits
What is covered The Plan pays for the following services
Mental conditions
Inpatient care Plan pays for ward or semiprivate accommodations and other hospital charges at 50 up to 50 days per calendar year after the stated deductible

PPO After satisfaction of a 400 deductible per admission Plan pays 50 of charges up to 50 days per benefit calendar year when admission is to a PPO hospital See page 6
Non PPO After satisfaction of a 500 deductible per admission Plan pays 50 of charges up to 50 days per benefit calendar year See page 5 When hospital charges are limited by law
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 page 26 for details

Inpatient visits See professional services below and outpatient
care
Catastrophic The Plan pays 100 of covered charges for the remainder of the calendar year after your coinsurance protection on out of pocket expenses for inpatient mental conditions care total 8,000 not to exceed the calendar year

maximum of 50 days
Substance abuse
Inpatient care After satisfaction of a separate 250 inpatient Substance Abuse calendar year deductible room and board and ancilliary charges for confinements in a treatment facility for rehabilitative treatment of alcoholism or

substance abuse are paid at 50 and are limited to a 30 day lifetime maximum per person see page 5 When hospital charges are limited by law

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 page 26 for details

Inpatient visits See Professional services below and outpatient
care
Lifetime There is a 30 day lifetime maximum per person for inpatient rehabilitative substance abuse care maximum

Mental conditions Substance abuse
Professional services
PPO After satisfaction of a 250 Mental conditions Substance abuse calendar year deductible the Plan pays benefit 60 of the negotiated rate for inpatient and outpatient services by covered providers for treatment of
mental conditions substance abuse up to a maximum of 30 visits
Non PPO After satisfaction of a 250 Mental conditions Substance abuse calendar year deductible the Plan benefit pays 50 of reasonable and customary charges for inpatient and outpatient services by covered providers

for treatment of mental conditions substance abuse up to a maximum of 30 visits
What is not covered Services by pastoral marital drug alcohol and other counselors Treatment for learning disabilities and mental retardation

Treatment for marital discord Services rendered or billed by schools residential treatment centers or halfway houses or members of
their staffs Room and board and doctor care when in the Carrier's judgement an admission or portion thereof is
not medically necessary i e the medical services did not require the acute care setting but could have been provided in a doctor's office hospital outpatient department or some other setting without
adversely affecting the patient's condition or the quality of care rendered
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

14 14
14 Page 15 16
NALC Health Benefit Plan 2000
Section 5 BENEFITS Other Medical Benefits
What is covered The Plan pays for the following services
Outpatient Benefits for visits to a doctor's office are covered as follows office visits

PPO After you pay a 15 copayment for each covered outpatient office visit with a PPO provider see page 6 the benefit Plan pays 100 of the negotiated rate The 275 calendar year deductible does not apply to this benefit
Home and hospital visits consultations and second opinions are covered under Other services below
Non PPO After the 275 calendar year deductible has been met the Plan pays 70 of reasonable and customary benefit charges for covered outpatient office visits provided by a non PPO provider

Other services
PPO After the 275 calendar year deductible has been met the Plan pays 85 of the negotiated rate for the benefit following services and supplies provided by a Plan PPO network provider See page 6

Non PPO After the 275 calendar year deductible has been met the Plan pays 70 of reasonable and customary charges benefit for the following services and supplies provided by a non PPO provider
Doctors nonsurgical services for home and hospital visits medical consultations and second surgical opinions except surgical followup care covered under Surgical Benefits
Initial examination of a newborn child covered under a Self and Family enrollment Acupuncture by a doctor of medicine or osteopathy

Services and supplies outside a hospital or as a hospital outpatient prescribed by the attending doctor as follows
Insulin and diabetic supplies also see prescription drug benefits page 18 Allergy tests and treatments including injectable antigens also see Allergy injections below

Needles and syringes for covered injectables and ostomy and catheter supplies Home IV and antibiotic therapy
Local professional ambulance service when medically appropriate Anesthetics and their administration
Oxygen Hemodialysis and peritoneal dialysis
Durable medical equipment also see Durable medical equipment below Artificial limbs and eyes stump hose also see Durable medical equipment below
Chemo and radiation therapy high dose chemotherapy in association with autologous bone marrow transplants is limited to those transplants listed on page 12
Blood and blood plasma if not donated or replaced Specially made durable leg arm neck and back braces
Diagnostic X rays laboratory tests and pathology services Outpatient hospital charges related to dental procedures only when necessitated by a non dental physical
impairment Externally worn breast prostheses and surgical bras including necessary replacements following a mastectomy
One pair of eyeglasses or contact lenses if required to correct an impairment directly caused by accidental ocular injury or intraocular surgery such as for cataracts
First hearing aid and testing only when necessitated by accidental injury
Allergy injections Professional services for the administration of allergy serum are payable as follows
PPO After you pay a 5 copayment the Plan pays 100 of the negotiated rate for each allergy injection benefit performed by a PPO provider See page 6

Non PPO After the 275 calendar year deductible has been met the Plan pays 70 of reasonable and customary benefit charges for services by a non PPO provider
Durable medical equipment DME

What is Rental or purchase at the Plan's option including repair and adjustment of oxygen apparatus dialysis covered appliances and similar durable medical equipment Also covered are hospital beds wheelchairs
crutches and walkers Arrangements have been made with a health care provider for purchase or rental of durable medical equipment at discounted rates Notify the Plan immediately at 1 800 433 NALC
when durable medical equipment has been prescribed
What is not DME replacements and prosthetic replacements provided less than 3 years after the last one covered for which benefits were paid

Sun or heat lamps whirlpool baths saunas and similar household equipment safety convenience and exercise equipment communication equipment including computer story boards or light talkers
enhanced vision systems computer switch boards or environmental control units heating pads air conditioners purifiers and humidifiers stair climbing equipment stair glides ramps elevators and
other modifications or alterations to vehicles or households and other items wigs that do not meet the definition of durable medical equipment on page 28

15 15
15 Page 16 17
NALC Health Benefit Plan 2000
Section 5 BENEFITS Other Medical Benefits continued
Routine services In addition to coverage of diagnostic X rays laboratory and pathology services and machine diagnostic tests the following routine screening services are covered as preventive care

PPO After you pay the applicable copayment shown below the Plan pays 100 of the negotiated rate benefit for services performed by a PPO provider See page 6
Non PPO After the 275 calendar year deductible has been met the Plan pays 70 of reasonable and benefit customary charges for the following services provided by a non PPO provider
PPO Copayment

Blood lead level Annual coverage of one blood lead level test 5 screening

Breast cancer Mammograms are covered for women age 35 and older as follows screening
From age 35 through 39 one mammogram screening during this five year period 25 From age 40 through 64 one mammogram screening every calendar year and 25

At age 65 and older one mammogram screening every two consecutive calendar years 25
Cervical cancer See Pap smears under Additional Benefits see page 17 screening

Colorectal cancer Annual coverage of one fecal occult blood test for members age 40 and older 5 screening See Screening sigmoidoscopy under Surgical Benefits see page 12
Prostate cancer Annual coverage of one PSA Prostate Specific Antigen test for men age 25 screening 40 and older
Blood cholesterol Total blood cholesterol test every three years ages 19 through 64 5 screening
Tetanus diphtheria Tetanus diphtheria Td booster every 10 years age 19 and over except as 5 immunization provided for under Childhood immunizations on page 17
Influenza Influenza and pneumococcal vaccines annually age 65 and over 5 Pneumococcal
vaccines
Strabismus Eye exam for amblyopia and strabismus once ages 2 through 6 15 Amblyopia

eye exam
Limited benefits
Growth hormone Growth hormone therapy GHT is covered only when preauthorization is obtained through the therapy Plan Call 1 800 433 NALC for preauthorization If no preauthorization is obtained before treatment

is begun GHT services will be covered only from the date that information is submitted to the Plan that establishes the medical necessity for GHT If the Plan determines that GHT is not medically
necessary the related services and supplies for GHT will not be covered Hospice care

What is covered The Plan will pay up to 3,000 per lifetime for inpatient and outpatient services administered as part of a Hospice care program see definition page 29
What is not Independent nursing homemaker or bereavement services covered
Rehabilitative The Plan will pay for up to 90 visits per calendar year for the services of each of the following therapy qualified physical speech and occupational therapists Visits to restore an attained bodily function or
speech when there has been a total or partial loss of bodily function or functional speech due to illness or injury will be covered when the following conditions are met 1 the care is ordered by the attending doctor
2 the doctor identifies the specific professional skills required by the patient and the medical necessity for skilled services and 3 the doctor indicates the length of time the services are needed

Smoking cessation After satisfaction of the calendar year deductible the Plan will pay up to 100 for enrollment in benefit one smoking cessation program per member per lifetime for all related expenses including drugs
What is not Orthopedic shoes foot orthotics arch supports elastic stockings lumbosacral supports covered corsets trusses and other supportive devices
Injections of silicone collagens and similar substances and all related charges
16 16
16 Page 17 18
NALC Health Benefit Plan 2000
Section 5 BENEFITS Other Medical Benefits continued
Eyeglasses hearing aids and examinations for them except as covered on page 15 orthoptics visual training and eye exercises
Routine physical checkups and related tests routine eye and hearing examinations immunizations and well child care except as listed on page 16 or covered under Additional Benefits
Treatment of weak strained or flat feet of bunions or spurs and of any instability imbalance or subluxation of the foot unless the treatment is by open cutting surgery
Services by chiropractors except in those states designated as medically underserved areas see page 6 Chelation therapy except for acute arsenic gold lead or mercury poisoning
Maintenance therapy including cardiac rehabilitation and exercise programs
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

Section 5 BENEFITS Additional Benefits
Accidental injury The Plan will pay 100 of the PPO negotiated rate or 100 of reasonable and customary outpatient charges for nonsurgical services and supplies by a doctor and for related outpatient hospital services
incurred within 48 hours after an accidental injury for treatment of that injury Charges incurred after 48 hours will be considered under Other Medical Benefits

Childhood Childhood immunizations recommended by the American Academy of Pediatrics are covered at 100 of immunizations reasonable and customary charges for dependent children age 3 to 22 The office visit on the day of the
immunization is covered under Other Medical Benefits
Pap smears The Plan will pay up to 35 per test Charges in excess of 35 and the office visit charge on the same day will be considered under Other Medical Benefits

Skilled nursing care
What is covered The Plan pays 80 of charges up to a maximum payment of 75 per day for up to 90 days per calendar year of skilled nursing care at home Charges of a registered nurse R N licensed practical nurse L P N

or licensed vocational nurse L V N are covered only when
1 the care is ordered by the attending doctor 2 the doctor identifies the specific professional skills required by the patient and the medical necessity

for skilled services and 3 the doctor indicates the length of time the services are needed

What is not Nursing care requested by or for the convenience of the patient or the patient's family nursing care primarily covered for hygiene feeding exercising moving the patient homemaking companionship or giving oral medication
Skilled nursing Plan pays for semiprivate room board services and supplies in a SNF up to a maximum of 30 days per facility SNF confinement except for mental conditions when 1 the patient is admitted directly from a precertified
hospital confinement of at least 3 consecutive days 2 admission is for the same condition as the hospital confinement and is under the supervision of a doctor 3 skilled nursing care is provided by an R N L P N
or L V N and 4 confinement is medically appropriate No admission deductible applies
PPO Plan pays room board and other charges at 100 when admission is to a PPO facility see page 6 benefit

Non PPO Plan pays room and board at 100 and other charges at 80 when admission is to a non PPO facility benefit

Well child care The Plan pays 100 of reasonable and customary charges for routine examinations immunizations and care for each eligible child to age 3 See Other Medical Benefits for the coverage of the initial newborn exam
Free 24 hour nurse For any of your health concerns 24 hours a day 7 days a week you may call 1 800 622 6252 and health resource line talk with a registered nurse who will discuss treatment options and answer your health questions
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

17 17
17 Page 18 19
NALC Health Benefit Plan 2000
Section 5 BENEFITS Prescription Drug Benefits
What is covered Each new enrollee will receive a description of the prescription drug program a combined prescription drug Plan identification card a mail order form patient profile and a preaddressed reply envelope You may
purchase the following medications and supplies prescribed by a doctor from either a pharmacy or by mail
Drugs and medicines including those for mental conditions and those administered during a noncovered admission or in a non covered facility that by Federal law of the United States require a

doctor's prescription for their purchase except as excluded below
A Federally approved generic equivalent will be dispensed if it is available unless your doctor specifically requires a name brand If you receive a name brand drug when a Federally approved

generic drug is available and your doctor has not specified the name brand drug you will be required to pay the difference in cost between the name brand drug and the generic

The Plan administers an open formulary If your physician believes a name brand product is necessary or there is no generic available your doctor may prescribe a name brand drug from a formulary list
This list of name brand drugs is a preferred list of drugs selected to meet patient needs at a lower cost to the Plan A brochure is available by calling 1 800 933 NALC

Insulin Needles and syringes for the administration of covered medications
Drugs for sexual dysfunction will only be covered when the dysfunction is caused by medically documented organic disease see Prior authorization below

What is not covered Drugs and supplies for cosmetic purposes Vitamins nutrients and food supplements even if prescribed or administered by a doctor
Nonprescription medicines
From a pharmacy You may purchase prescription drugs either from retail pharmacies that are part of the Plan's CareSelect Pharmacy Network or from non Network pharmacies

Network retail After the 25 calendar year drug deductible 50 per family and applicable copayment 5 generic pharmacy 10 name brand has been met the Plan pays 100 of covered charges Present your NALC card to the
pharmacy with your prescription and pay any applicable deductible and copayment You may obtain up to a 30 day supply plus one refill for each prescription purchased from a CareSelect Network pharmacy The
CareSelect Network pharmacy files your claim and is reimbursed by the Plan After one refill you must obtain a new prescription and submit it to the mail order program Note Failure to do so will result in
benefits payable at the non Network retail pharmacy benefit level
Non network After the 25 calendar year drug deductible 50 per family has been met the Plan pays 60 and retail pharmacy you pay 40 of covered charges for up to a 30 day supply and unlimited refills You will need to file a

claim for reimbursement
By mail You may order up to a 90 day 21 day minimum supply of medications for a 12 copayment for a generic drug 25 copayment for a name brand drug per prescription or refill No deductible applies Allow two

weeks for delivery Please note that medications dispensed through the mail order program are subject to the following standards the professional judgement of the pharmacist limitations imposed on controlled
substances manufacturer's recommendations and applicable state law In most cases refills cannot be obtained until 75 of the drug has been used

Use the NALC mail order form patient profile and preaddressed envelope with your first order Mail these with your prescription s and a check for 12 per generic or 25 per name brand for each prescription or refill to
NALC Prescription Drug Program P O Box 380
Lincolnshire IL 60069 0380
Prior authorization Some drugs require prior authorization Call the Plan at 1 800 433 NALC for information Maximum dosage dispensed may be limited by protocols established by the Plan

Waivers The following waivers apply if you have Medicare Part B and Medicare is the primary carrier If you purchase your prescriptions from CareSelect Network retail pharmacies your deductible will be waived
and your copayments will be 1 per generic and 2 per name brand drug see Network retail pharmacy above If you purchase your prescriptions from non Network retail pharmacies however only your
calendar year deductible will be waived If you order by mail your copayments will be 2 per generic and 4 per name brand drug and no deductible will apply

18 18
18 Page 19 20
NALC Health Benefit Plan 2000
Section 5 BENEFITS Prescription Drug Benefits continued
To claim When you use a non Network pharmacy or you use a CareSelect Network pharmacy and are unable to use benefits your card complete the Short Term Prescription claim form and mail with your prescription receipts to

NALC Prescription Drug Program P O Box 686005
San Antonio TX 78268 6005
Receipts must specify the prescription number name of drug prescribing doctor's name date charge and name of drugstore

Double coverage When there is double coverage and the other carrier is primary use that carrier's drug benefit first and call 1 800 933 NALC to request a Short Term claim form After the primary carrier has processed the claim complete
the claim form attach the drug receipts and the other carrier's Explanation of Benefits form and mail to
NALC Prescription Drug Program P O Box 686005

San Antonio TX 78268 6005
Questions If you have any questions about the Program wish to locate a CareSelect Network retail pharmacy or need additional claim forms call 1 800 933 NALC 8 30 a m 10 00 p m Mon Fri 9 00 a m 1 00 p m

Sat Eastern time
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

19 19
19 Page 20 21
NALC Health 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 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 procedure

The following non FEHB Program benefit is available only to letter carriers who are members in good standing with the National Association of Letter Carriers their spouses children and retired NALC members

Hospital Plus Hospital Plus is a hospital indemnity policy available for purchase from the U S Letter hospital Carriers Mutual Benefit Association
indemnity Hospital Plus means money in your pocket when you are hospitalized from the first day
of your stay up to one full year These benefits are not subject to federal income tax
Hospital Plus allows you to choose the amount of coverage you need You may elect to receive up to 2,250 a month 75 a day or up to 1,500 a month 50 a day or up to 900

a month with the 30 a day plan Members and their spouses may select these plans Children's coverages are limited to either 45 a day 30 a day or 18 a day plans

Use your benefits to pay for travel to and from the hospital childcare medical costs not covered by health insurance legal fees or any other costs
This plan is available to all qualified members regardless of their age Hospital Plus is renewable for life you may keep your policy for as long as you like regardless of
benefits you have received or future health conditions
For more information please call the United States Letter Carriers Mutual Benefit Association at 202 638 4318 Monday through Friday or 1 800 424 5184 Tuesdays and

Thursdays 8 00 a m 3 30 p m EST

Benefits on this page are not part of the FEHB contract
20 20
20 Page 21 22
NALC Health Benefit Plan 2000
Section 6 How to File a Claim
How to Claim Benefits
Claim forms If you do not receive your identification card s within 60 days after the effective date of your enrollment identification call the Carrier at 1 800 433 NALC to report the delay In the meantime use your copy of the SF 2809

cards and enrollment form or your annuitant confirmation letter from OPM as proof of enrollment when you obtain questions services This is also the number to call for claim forms or advice on filing claims

If you have a question concerning Plan benefits contact the Carrier at 703 729 4677 or you may write to the Carrier at 20547 Waverly Court Ashburn VA 20149 0001
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 file Claims filed by your doctor that include an assignment of benefits to the doctor are to be filed on the form claims 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 Signature of physician or supplier including degrees or credentials of individual providing the service
Dates that services or supplies were furnished Type of each service or supply CPT HCPCS Code and the charge
Diagnosis ICD 9 Code
In addition
A copy of the explanation of benefits EOB from any primary payer such as Medicare must be sent with your claim

Bills for private duty nurses must show that the nurse is a registered 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 overseas foreign services should include an English translation Charges should be converted to U S dollars using the exchange rate applicable at the time the expense was incurred

Cancelled checks cash register receipts or balance due statements are not acceptable
After completing a claim form and attaching proper documentation send all claims except prescription drug claims to NALC Health Benefit Plan 20547 Waverly Court Ashburn VA 20149 0001

Phone 703 729 4677
See pages 18 19 for instructions on filing prescription drug claims
Verification of benefits is valid only when provided by the NALC Health Benefit Plan at the above address
Hospitals may call 1 800 548 8454 for confirmation of benefits
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 The Carrier will not pay benefits for claims submitted more than two years from the date the claims expense was incurred unless timely filing was prevented by administrative operations of Government or
promptly legal incapacity provided the claim was submitted as soon as reasonably possible To avoid denial of payment submit claims on a timely basis Once benefits have been paid there is a three year limitation on
the reissuance of uncashed checks
Direct payment Other Medical Benefits subject to the deductible may not ordinarily be assigned but will be to hospital or paid directly to the enrollee Use the Claim Form for Unassigned Bills CF 2 for filing

provider of care Hospital benefits To authorize direct payment to a hospital present your identification card upon
admission and complete the hospital's standard authorization assignment of benefits form or the NALC Hospital Claim Form H 1

Doctor benefits To authorize direct payment to a doctor or surgeon complete Form HCFA 1500 Health Insurance Claim Form available through your provider's office
21 21
21 Page 22 23
NALC Health Benefit Plan 2000
Section 6 How to File a Claim continued
When more Reply promptly when the Carrier requests information in connection with a claim If you do not respond the information Carrier may delay processing or limit the benefits available The Carrier its medical staff and or an
is needed independent medical review determines whether services supplies and charges meet the coverage requirements of the Carrier subject to the disputed claims procedure described on pages 8 9 The Carrier is also
entitled to obtain medical or other information including an independent medical examination that it may in its discretion consider useful to determine if a service or supply is covered

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 a covered provider has
prescribed recommended or approved a service or supply does not make it medically necessary or eligible for coverage under this Plan
Exclusions listed with a single benefit category may apply to other categories Refer to Section 5 BENEFITS to assure that you are aware of all exclusions

We do not cover Services drugs or supplies that are not medically necessary the following Services drugs or supplies 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 except as
provided on page 18 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 Charges that would not be made if a covered individual had no health insurance
Services furnished without charge except as described on page 25 while on 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 household members or immediate relative such as spouse parent child brother
or sister by blood marriage or adoption Charges furnished or billed by a noncovered facility except medically necessary prescription drugs
All services for and related to a procedure not listed as covered Charges furnished or billed by noncovered providers
Any portion of a charge ordinarily due from you such as a deductible coinsurance and copayment that has been waived We will reduce the billed charge by the amount waived
Charges for which you or the Plan have no legal obligation to pay such as excess charges for an annuitant age 65 or older who is not covered by Medicare Parts A and or B see page 26 doctor
charges exceeding the amount specified by the Department of Health and Human Services when benefits are payable under Medicare limiting charge see page 24 or State premium taxes however
applied Charges in excess of the reasonable and customary amount
Any treatment for cosmetic purposes Custodial care as defined on page 28
Injections of growth hormones and related supplies except when preauthorization has been obtained through the Plan
Charges for interest completion of claim forms missed or cancelled appointments and administrative fees
Nonmedical social services recreational therapy training in activities of daily living educational and training services
Nonsurgical treatment for weight reduction or obesity Speech therapy except as provided on page 16
Testing for mental aptitude or scholastic ability Therapy for developmental delays learning disabilities stuttering tongue thrusting or deviate swallowing
Transportation or travel other than ambulance services and travel under the managed transplant system and
Dental services and supplies except those oral surgical procedures listed on page 12

22 22
22 Page 23 24
NALC Health Benefit Plan 2000
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 and this Plan 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 reenroll 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 re enroll 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
This Plan and Medicare
Coordinating The following information applies only to enrollees and covered family members who are entitled to benefits benefits from both this Plan and Medicare You must disclose information about Medicare coverage
including your enrollment in a Medicare Choice plan to this Carrier this applies whether or not you file a claim under Medicare You must also give this Carrier authorization to obtain information about benefits
or services denied or paid by Medicare when they request it It is also important that you inform the Carrier about other coverage you may have as this coverage may affect the primary secondary status of this Plan
and Medicare see page 25
This Plan covers most of the same kinds of expenses as Medicare Part A hospital insurance and Part B medical insurance except that Medicare does not cover prescription drugs

The following rules apply to enrollees and their family members who are entitled to benefits from both an FEHB plan and Medicare
This Plan is 1 You are age 65 or over have Medicare Part A or Parts A and B and are employed by the primary if Federal Government
2 Your covered spouse is age 65 or over and has Medicare Part A or Parts A and B and you are employed by the Federal Government
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 primary if not employed by the Federal Government

2 Your covered spouse is age 65 or over and has Medicare Part A or Parts A and B and you are not employed by the Federal Government
3 You are age 65 or over and a you are a Federal judge who retired under title 28 U S C b you are a Tax Court judge who retired under Section 7447 of title 26 U S C or c you are the covered spouse
of a retired judge described in a or b 4 You are an annuitant not employed by the Federal Government and either you or a covered family
member who may or may not be employed by the Federal Government is under age 65 and eligible for Medicare on the basis of disability
5 You are enrolled in Part B only regardless of your employment status 6 You are age 65 or over and employed by the Federal Government in an appointment that excludes similarly
appointed nonretired employees from FEHB coverage and have Medicare Part A or Parts A and B 7 You are a former Federal employee receiving workers compensation and the Office of Workers
Compensation has determined that you are unable to return to duty 8 The patient you or a covered family member has completed the 30 month ESRD coordination period
and is still eligible for Medicare due to ESRD or 9 The patient you or a covered family member becomes eligible for Medicare due to ESRD after
Medicare assumed primary payer status for the patient under rules 1 through 7 above
23 23
23 Page 24 25
NALC Health Benefit Plan 2000
Section 8 Limitations Rules that affect your benefits continued
When Medicare When Medicare is primary all or part of your Plan deductibles coinsurance and copayments will is primary be waived as follows
Inpatient Hospital Benefits If you are enrolled in Medicare Part A the Plan will waive the deductible and coinsurance
Surgical Benefits If you are enrolled in Medicare Part B the Plan will waive the deductible and coinsurance Mental Conditions Substance Abuse Benefits If you are enrolled in Medicare Part A the Plan
waives the inpatient deductible and coinsurance for hospital charges If you are enrolled in Medicare Part B the Plan waives the deductible and coinsurance for professional services and confinements in
treatment facilities Benefit limits and the calendar year maximum will not be waived Other Medical Benefits If you are enrolled in Medicare Part B the Plan waives the deductible
coinsurance and outpatient office visit copayments The lifetime maximum for hospice care will not be waived Additional Benefits If you are enrolled in Medicare Part B the Plan waives the coinsurance for
skilled nursing care and the skilled nursing facility coinsurance Prescription Drug Benefits If you are enrolled in Medicare Part B the Plan waives the deductible
required for purchases from a network or non network retail pharmacy However the stated copayments or coinsurance for Medicare recipients will not be 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 Choice plan while you are a member of this Plan you may continue enroll in a to obtain benefits from this Plan If you submit claims for services covered by this Plan that you receive
Medicare from providers that are not in the Medicare plan's network the Plan will not waive any deductibles or Choice plan 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 payment and for services covered by both this Plan and Medicare Part B will depend on whether your doctor accepts
this Plan Medicare assignment for the claim
Doctors who participate with Medicare accept assignment that is they have agreed not to bill you for more than the Medicare approved amount for covered services Some doctors who do not participate with

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

the Social Security Act 42 U S C sets a limit on how much you are obligated to pay This amount called the limiting charge is 115 percent of the Medicare approved amount Under this law if you use a
doctor who does not accept assignment for the claim the doctor is permitted to bill you after the Plan has paid only if the Medicare and Plan payments combined do not total the limiting charge Neither you nor
your FEHB Plan is liable for any amount in excess of the Medicare limiting charge for charges of a doctor who does not participate with Medicare The Medicare Summary Notice MSN 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 In any case a doctor who does not participate with Medicare is not entitled to payment of more than 115
percent of the Medicare approved amount
How to claim In most cases when services are covered by both Medicare and this Plan Medicare is the primary payer if benefits you are an annuitant and this Plan is the primary payer if you are an employee Your provider should

submit your claims to Medicare and after Medicare has paid its benefits this Plan will consider the balance of any covered expenses This Plan has contracted with Medicare Part B carriers to receive electronic
copies of your claims after Medicare has paid their benefits This eliminates the need for you to submit your Part B claims to this Plan Your copy of the Plan's explanation of benefits will indicate if your claims
are being filed electronically If they are not you must submit the Medicare Summary Notice with duplicates of all bills and a completed claim form This Plan will not process your claim until the Medicare
Summary Notice is received
24 24
24 Page 25 26
NALC Health Benefit Plan 2000
Section 8 Limitations Rules that affect your benefits continued
Other group When you have coverage with us and another group health plan or medical coverage with an auto insurance insurance company that pays health benefits without regard to fault it is called Double Coverage Coordination of
coverage Benefits You must send us information about the other insurance if you or a family member has Double Coverage
When you have Double Coverage one plan pays its benefits in full as the primary payer and the other plan pays a reduced benefit as the secondary payer We decide which group health plan is primary according to

the National Association of Insurance Commissioners Guidelines When health benefits are payable by auto insurance the auto insurer is primary if it is legally obligated to provide benefits without regard to
other health coverage you have
If we pay second we will determine how much of the charge is allowable After the first plan pays we will pay either what is left the allowable charge or our regular benefit whichever is less The total

payments of all plans will never be more than the allowable charge
We will apply this provision whether or not a claim is filed with the other plan
When others are responsible for

injuries
Liability insurance Subrogation applies when you are sick or injured as a result of the act or omission of another person or and third party party Subrogation means the Plan's right to recover payments made to you or your dependent by a third

actions party or third party's insurer because of illness or injury caused by a third party Third party means another person or organization If you or your covered dependent suffers an injury or illness through the act or
omission of another the Plan requires that it be reimbursed for benefits paid by the Plan in an amount not to exceed the amount of the recovery or that it 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 the Plan for benefits paid The Plan's share of
the recovery will not be reduced because you or your dependent do not receive the full amount of damages claimed unless the Plan agrees in writing to a reduction

If you or your dependent are injured because of a third party's action or omission 1 The Plan will pay benefits for that injury subject to the conditions that you and your dependent a do not take any action that
would prejudice the Plan's ability to recover benefits and b will cooperate in doing what is reasonably necessary to assist the Plan in any recovery 2 The Plan's right of reimbursement extends only to the
amount of Plan benefits paid or to be paid because of the injury 3 The Plan 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 the Plan promptly of any third party claim that you may have for damages for which the Plan has paid or may pay benefits In addition you are required to notify the Plan of any recovery

whether in or out of court that you or your dependent obtain and to reimburse the Plan to the extent of benefits paid by the Plan Any reduction of the Plan's claim for payment of attorney's fees or costs associated
with the claim is subject to prior approval by the Plan If you need more information about subrogation the Plan will provide you with its subrogation procedures

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
We are entitled to be reimbursed by OWCP or similar agency for benefits paid by us that were later found to be payable by OWCP or the agency

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 Agencies indirectly pays for

Overpayments The Carrier 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

25 25
25 Page 26 27
NALC Health Benefit Plan 2000
Section 8 Limitations Rules that affect your benefits continued
Vested rights An enrollee does not have a vested right to the benefits in this brochure in 2001 or later years and does not have a right to benefits available prior to 2000 unless those benefits are contained in this brochure
Limit on your costs The information in the following paragraphs applies to you when 1 you are not covered by either Medicare if you're age 65 or Part A hospital insurance or Part B medical insurance or both 2 you are enrolled in this Plan as an
older and don't annuitant or as a former spouse or family member covered by the family enrollment of an annuitant or have Medicare former spouse and 3 you are not employed in a position which confers FEHB coverage

Inpatient If you are not covered by Medicare Part A are age 65 or older or become age 65 while receiving inpatient hospital care 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 the Plan for assistance

Physician Claims for physician services provided for retired FEHB members age 65 and older who do not have Medicare services Part B are also processed in accordance with 5 U S C 8904 b This law mandates the use of Medicare
Part B limits for covered physician services for those members who are not covered by Medicare Part B
The Plan is required to base its payment on the Medicare approved amount which is the Medicare fee schedule for the service or the actual charge whichever is lower If your doctor is a member of the 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 doctor who does not participate with Medicare you are responsible for any deductible and the copayment or coinsurance In addition unless the doctor's agreement with the Carrier specifies
otherwise you must pay the difference between the Medicare approved amount and the limiting charge 115 of the Medicare approved amount

If your physician is not a Plan PPO doctor but participates with Medicare the Plan will base its regular benefit payment on the Medicare approved amount For instance under this Plan's surgery benefit the
Plan will pay 70 of the Medicare approved amount You will only be responsible for any deductible and coinsurance equal to 30 of the Medicare approved amount

If your physician does not participate with Medicare the Plan will still base its payment on the Medicareapproved 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 the Plan for assistance

Section 9 Fee For Service Facts
Precertification Precertify Precertification is not a guarantee of benefit payments Precertification of an inpatient admission is a

before admission predetermination that based on the information given the admission meets the medical necessity requirements of the Plan It is your responsibility to ensure that precertification is obtained If precertification is not
obtained and benefits are otherwise payable benefits for the admission will be reduced by 500
To precertify a scheduled admission
You your representative your doctor or your hospital must call the Carrier prior to admission The toll free number is 1 800 622 6252

Provide the following information enrollee's name and Plan identification number patient's name birth date and phone number reason for hospitalization proposed treatment or surgery name of hospital or
facility name and phone number of admitting doctor and number of planned days of confinement
26 26
26 Page 27 28
NALC Health Benefit Plan 2000
Section 9 Fee For Service Facts continued
A review coordinator will then tell the doctor and hospital the number of approved days of confinement for the care of the patient's condition Written confirmation of the Carrier's certification decision will be sent
to you your doctor and the hospital If the length of stay needs to be extended follow the procedures below
Need additional A review coordinator will contact your doctor before the certified length of stay ends to determine if you days will be discharged on time or if additional inpatient days are medically necessary If the admission is

precertified but you remain confined beyond the number of days certified as medically necessary the Carrier will not pay for charges incurred on any extra days that are not determined to be medically necessary
by the Carrier during the claim review
You don't need Medicare Part A or another group health insurance policy is the primary payer for the hospital confinement to certify an see pages 23 25 Precertification is required however when Medicare hospital benefits are exhausted

admission when prior to using the lifetime reserve days You are confined in a hospital outside the United States and Puerto Rico
The discharge for your maternity admission is within 48 hours after a regular routine delivery or within 96 hours after a cesarean delivery

Maternity or When there is an emergency admission due to a condition that puts the patient's life in danger or could cause serious emergency damage to bodily function you your representative the doctor or the hospital must telephone 1 800 622 6252
admissions 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

Newborn confinements that extend beyond the mother's discharge date must also be certified You your representative the doctor or hospital must request certification for the newborn's continued confinement
within two business days following the mother's discharge
Other An early determination of need for confinement precertification of the medical necessity of inpatient considerations admission is binding on the Carrier unless the Carrier is misled by the information given to it After the

claim is received the Carrier will first determine whether the admission was precertified and then provide benefits according to all of the terms of this brochure

If you do not If precertification is not obtained before admission to the hospital or after 48 hours after a regular routine precertify delivery or 96 hours after a cesarean section delivery or within two business days following the day of an
emergency admission or in the case of a newborn the mother's discharge a medical necessity determination will be made at the time the claim is filed If the Carrier determines that the hospitalization was not
medically necessary the inpatient hospital benefits will not be paid However the 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

Protection Against Catastrophic Costs
Catastrophic For those services with coinsurance the Plan pays 100 no deductible or coinsurance applies of reasonable protection and customary charges for the remainder of the calendar year after covered out of pocket expenses under
Inpatient Hospital Surgical Maternity Other Medical Benefits and Additional Benefits Skilled nursing facility only total 3,500 per individual or 3,500 per family Out of pocket expenses for the purposes of
this benefit are
The 20 you pay under Non PPO Inpatient Hospital Benefits The 30 15 PPO you pay under Surgical Benefits

The 30 15 PPO you pay under Other Medical Benefits and The 20 you pay under Additional Benefits for care in a skilled nursing facility

The following cannot be counted toward out of pocket expenses
All deductibles All copayments for PPO providers

Expenses incurred under Additional Benefits for skilled nursing care Expenses incurred under Prescription Drug Benefits
Expenses in excess of reasonable and customary charges or maximum benefit limitations Expenses for mental conditions or substance abuse and
Any amounts you pay because benefits have been reduced for non compliance with this Plan's cost containment requirements see page 4

27 27
27 Page 28 29
NALC Health Benefit Plan 2000
Section 9 Fee For Service Facts continued
PPO When your eligible out of pocket expenses from using PPO providers exceed 3,000 per individual or providers 3,000 per family the Plan pays 100 of its covered PPO charges for covered services when you continue
to select PPO providers for the remainder of the calendar year Whether or not you use PPO providers your share of out of pocket expenses will not exceed 3,500 per individual or 3,500 per family in a
calendar year
Mental The Plan pays 100 of covered charges for the remainder of the calendar year after coinsurance out ofConditions pocket expenses for inpatient mental conditions care total 8,000 not to exceed the calendar year maximum

Benefit of 50 days
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 of pocket 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

Definitions Accidental injury A bodily injury sustained solely through violent external and accidental means

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
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
Calendar year January 1 through December 31 of the same year For new enrollees the calendar year begins on the effective date of their enrollment and ends on December 31 of the same year
Congenital A condition existing at or from birth which is a significant deviation from the common form or norm For anomaly 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

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 Plan determines which services are custodial care
Durable medical Equipment and supplies that equipment
1 are prescribed by your attending doctor 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

28 28
28 Page 29 30
NALC Health Benefit Plan 2000
Section 9 Fee For Service Facts continued
Effective date The date the benefits described in this brochure are effective
1 January 1 for continuing enrollments and for all annuitant enrollments 2 the first day of the first full pay period of the new year for enrollees who change plans or options or

elect FEHB coverage during the open season for the first time or 3 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
Experimental or See page 8 investigational

Group health Health care coverage that a member is eligible for because of employment membership in or connection coverage with a particular organization or group that provides payment for hospital medical or 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

Hospice care A coordinated program of maintenance and supportive care for the terminally ill provided by a medically program supervised team under the direction of a Plan approved independent hospice administration
Incurred date The date when the service or supply is received The benefits that apply are those in effect on the date the charge is incurred
Medically Services drugs supplies or equipment provided by a hospital or covered provider of the health care necessary services that the Plan 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

Mental conditions Conditions and diseases listed in the most recent edition of the International Classification of Diseases substance abuse ICD as psychoses neurotic disorders or personality disorders other nonpsychotic mental 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

Morbid obesity A condition wherein an individual 1 is the greater of 100 pounds or 100 over normal weight with complicating medical conditions and 2 has been so despite documented attempts to reduce using a doctormonitored
diet and exercise program
Pre admission Routine tests ordered by a doctor and usually required prior to surgery or hospital inpatient admission that testing are not diagnostic in nature

Reasonable and The benefits of this Plan are limited to and based on reasonable and customary charges except for customary negotiated rates with PPO providers Network retail pharmacies and mail order pharmacies The reasonable
and customary charge for any service or supply is the prevailing charge made by other providers within the geographic area in which the service or supply is provided for illness or injury of comparable severity and
nature in the absence of insurance The Plan determines reasonable and customary charges from data prepared by Ingenix Inc including both the Prevailing Healthcare Charges System PHCS and Medical
Data Research MDR data For inpatient and outpatient Surgical Benefits data is from PHCS For physician and other professional services and laboratory and X ray procedures under Other Medical
Benefits the Plan uses data prepared by MDR The Plan pays claims based on the 90th percentile for both PHCS and MDR This data is updated twice per year For other categories of benefits and for certain
specific services within each of the above categories exceptions to the general method of determining reasonable and customary may exist

29 29
29 Page 30 31
NALC Health Benefit Plan 2000
Section 10 FEHB FACTS
You have a right to the following information 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 out about care management which includes medical practice guidelines disease management 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 703 729 4677 or write to NALC Health Benefit Plan 20547 Waverly Court Ashburn VA 20149 0001 You may also visit our website at www nalc org hbp for
general information
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal Employees information about Health Benefits Plans brochures for other plans and other materials you need to make an informed decision

enrolling in the about FEHB Program
When you may change your enrollment 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 benefits and premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants
premiums premiums begin January 1 If you are in the hospital on the effective date see page 7 effective

What happens When you retire you can usually stay in the FEHB Program Generally you must have been enrolled in when I retire the FEHB Program for the last five years of your Federal service If you do not meet this 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 coverage are dependent children under age 22 including any foster or step children your employing or retirement office
available for me authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 and my family years of age or older who became incapable of self support before age 22

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 or receive benefits from 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
OPM when reviewing a disputed claim or defending litigation about a claim As part of its administration of the prescription drug benefits the Plan may disclose information about
a member's prescription drug utilization including the name of prescribing physicians to any treating physicians or dispensing pharmacies

30 30
30 Page 31 32
NALC Health Benefit Plan 2000
Section 10 FEHB FACTS continued
Information for new members
Identification We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF 2809 cards or the OPM annuitant confirmation letter until you receive your 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 FEHB 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 You will receive an additional 31 days of coverage for no additional premium when my enrollment in
Your enrollment ends unless you cancel your enrollment or this 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 If you are divorced from a Federal employee or annuitant you may not continue to get benefits under your spouse coverage 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
How do I enroll If you leave Federal service your employing office will notify you of your right to enroll under TCC You in TCC 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 he or she becomes eligible for TCC or receives 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

31 31
31 Page 32 33
NALC Health Benefit Plan 2000
Section 10 FEHB FACTS continued
How can I You may convert to an individual policy if convert to
Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not pay individual your premium you cannot convert
coverage 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 indicates how long you have been enrolled with us You can use this certificate when getting health

Group Health insurance or other health care coverage You must arrange for the other coverage within 63 days of leaving Plan Coverage this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions 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

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

Who is Eligible DoD determines who is eligible to enroll in FEHB 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 Your first opportunity to enroll will be during the 1999 Open Season November 8 1999 through December I Join 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

32 32
32 Page 33 34
NALC Health Benefit Plan 2000
Section 10 FEHB FACTS continued
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 and

Continuation of family enrollment This occurs when a child turns 22 for example or if you divorce and your spouse does Coverage TCC not qualify to enroll as an unremarried former spouse under title 10 United States Code 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

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 These provisions do not apply to the DoD FEHBP Demonstration Project 31 Day 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 800 433 NALC 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 NW Room 6400 Washington D C 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

33 33
33 Page 34 35
NALC Health Benefit Plan 2000
Index
Abortion 22 Cost Sharing 5 Hospital admissions 10 Morbid obesity 11 22 29 Primary payer 21 23 24 25 Accidental injury 15 17 28 Counselors 14 13 14 26 27 Multiple or bilateral surgical Privacy Act statement 9
Acupuncture 15 Covered facilities providers Hospital bassinet nursery 13 procedures 11 Private duty nursing 11 21 Additional Benefits 17 6 Hospital inpatient benefits
National Transplant Private room 10 17 Admission 10 13 14 17 Crutches 15 10 11 Program 12 Professional charges 10

26 28 Custodial care 22 28 Humidifiers 15 Needles syringes 15 18 11 14 Alcoholism 6 14
Days certified 26 27 Identification cards 21 31 Negotiated rate 6 7 Prostate cancer screening 16 Allergy tests injectable Deductible 5 10 11 13 18 Immunizations 16 17 Network retail pharmacy Prostate specific antigen

antigens 15 27 Implants 12 18 19 24 PSA 16 Allogeneic bone marrow
Definitions 28 29 In vitro fertilization 13 Newborn examination 15 17 Protection Against Catastrophic transplant 12 Diabetic supplies insulin Incidental procedures 11 No fault see auto insurance Costs 27 28

Amblyopia 16 15 18 Incurred date 29 Non FEHB Benefits 20 Providers covered 6 Ambulance 10 15 22
Diagnostic tests 10 13 15 Individual Coverage 32 Non network retail Psychologist 6 Anesthetics 10 15 Dialysis 15 Infertility 13 pharmacy 18 19 24 Radiation therapy 15

Anesthesiologist 10 11 Disputed claims 4 8 9 22 Influenza vaccine 16 Non PPO provider 4 5 7 Radiologist 10 11 Appliances 11 15
D O D Demonstration Information you have a 10 17 19 27 Reasonable customary 29 Artificial insemination 13 Project 32 33 right to know 30 Nonprescription medicine 18 Registered nurse R N 17

Artificial limbs eyes 15 Donor expenses 11 Injectables 15 Nonsurgical treatment 15 Rental equipment 15 21 Artificial organs 12
Double coverage 19 25 Inpatient Hospital Benefits 17 22 Residential treatment center Assignment 21 24 28 Drugs medicines 10 10 11 Nurse anesthetist 6 11 14

Assistant surgeon 11 15 18 19 Inspector General Advisory C R N A 6 Reversal of surgical Assisted reproductive
Durable medical equipment fraud 33 Nurse Health Resource Line sterilization 12 technology ART 13 DME 15 21 28 Insulin diabetic supplies 4 17 Room board 10 11 13
Audits 30 Effective date 5 21 22 15 18 Nurse practitioner clinical 14 17 Autologous bone marrow

28 30 Intensive care unit 10 13 specialist 6 Routine physical exam 17 transplant ABMT 12 15 Embryo transfer 13 Intraocular surgery 15 Nurses R N L P N L V N Routine services 16
Autologous peripheral stem Emergency admission 10 Investigational experimental 17 cell support 12

14 27 treatment 8 22 Nursing facility skilled Schools 11 14 Auto insurance 25 Employee Express 21 31 Itemized bills 21 SNF 6 11 17 24 Second surgical opinions 15
Bilateral surgical Enrollment Information IV therapy 15 Nursing home 6 11 Semiprivate accommodation procedures 11
31 32 Nursing school administered 10 13 14 17 Birthing center 13 Equipment durable medical Keratotomy 12 clinic 6 Sigmoidoscopy screening
Blood blood plasma 10 15 DME 15 21 28 Kidney transplant 11 12 Obesity 11 22 29 4 12 16 Blood lead level screening 16
Exclusions not covered Laboratory tests 10 13 15 16 Obstetrical care 7 13 Skilled nursing care 17 Bone marrow transplant 12 15 11 18 Laws Federal 9 18 Occupational therapist 16 21 Skilled nursing facility
Braces 15 Exercise equipment 15 Learning disabilities 14 22 Ocular injury 15 SNF 6 11 17 Breast cancer screening 16
Experimental investigational Liability Insurance 25 Optometrist 6 Smoking cessation benefit Breast prosthesis 10 15 drug device Licensed practical nurse Oral maxillofacialsurgery 12 6 16

Calendar year deductible treatment 8 22 L P N 17 Oral implants transplants 12 Sonogram 13 5 7 11 13 16 18 Extended care facility 6 11 Licensed vocational nurse Organ tissue transplants Spouse coverage former

Carryover 5 28 External breast prosthesis 15 L V N 17 11 12 31 32 33 Catastrophic Protection
Eye examination 16 17 Lifetime maximum 6 14 Ostomy catheter supplies 15 Speech therapist 16 22 14 27 28 Eyeglasses 15 17 Limb artificial 15 Other Medical Benefits Standby physicians

Cervical cancer screening Limitations 23 26 15 16 surgeons 12 Pap smear 16 17 Facilities Providers 6 Liver transplant 11 12 Out of pocket expenses 5 Sterilization 11 12

CHAMPUS 25 Facility treatment 6 14 Lung transplant 11 12 6 27 28 Strabismus 16 Charges reasonable Family limit 5 Machine diagnostic tests 16 Outpatient care 4 7 11 Submission of Claims 21
customary 29 Fecal occult blood test 16 Mail order prescription drug 13 17 24 Subrogation provision 25 Chelation therapy 17 Flexible benefits option 4 program 18 19 Outpatient surgery 10 11 13 Substance Abuse Benefits
Chemotherapy radiation Former spouse coverage Mammogram screening 16 Overpayments 25 6 14 therapy 15 31 33 Mastectomy 10 12 15 Oxygen 10 15 Summary of Benefits 35
Cholesterol screening 16 Fraud 33 Maternity Benefits 6 13 27 Pap smear 16 17 Surcharge 11 Claim forms 19 21 22 Gamete intrafallopian Maxillofacial surgery 12
Pathologist 7 10 11 Surgical Benefits 11 12 Claiming benefits 21 22 transfer GIFT 13 Maximum limiting charge 24 Per admission deductible 5 7 Table of Contents 2

Cleft palate lip 12 28 Gastric bypass 11 26 10 13 14 24 Temporary continuation of Clinical psychologist social General Exclusions 22 Maximums 6 12 14 17
Peritoneal dialysis 15 coverage TCC 31 33 worker 6 Genetic counseling 13 27 28 Personal comfort items Third party liability 25

Coinsurance 5 27 28 Group B streptococcus Medicaid 25 11 29 Transplant organ tissue Colorectal cancer screening infection 13 Medical equipment durable
Physical therapist 16 21 11 12 16 Group health coverage 25 DME 4 15 21 28 Pneumococcal vaccine 16 Treatment facility 6 14

Community mental health 27 29 32 Medically necessary 10 11 Podiatrist 6 TRICARE 25 organization 6 Growth hormone 16 22 12 13 14 16 22 27 28 29
Practical nurse L P N 17 Vitamins 18 Confidentiality 30 Halfway house 11 14 Medically underserved Pre admission testing 10 29 Vocational nurse L V N

Congenital anomaly 12 28 Hearing aid examination areas MUA 4 6 17 Precertification 4 10 13 17 Consultations 15 15 17 Medicare 23 24 14 26 27
Waivers 10 18 24 Continuation of coverage Heating lamp pad 15 Medicare 65 and over no Preferred provider organization Walker 15
temporary TCC 30 31 Hemodialysis 15 Medicare 22 26 PPO 3 7 10 11 Weight reduction 22 32 33 Home office visits 15 17 Medicare waiver 10 18 27 13 17 28

Well child care 17 Conversion 32 33 Home IV therapy 15 Medicines see drugs Premiums 4 30 36 Wheelchair 15
Coordination of benefits 25 Home nursing care 17 Mental Conditions Substance Prescription Drug Benefits Workers compensation 25 Copayment 5 15 16 18 27 Hospice care 6 16 29 Abuse Benefits 14 29 18 19 24

Cosmetic surgery 12 28 Hospital 6 Midwife 6 13 Preventive care 16 17 X rays 10 15 16 29
34 34
34 Page 35 36
NALC Health Benefit Plan 2000
Summary of Benefits for the NALC Health Benefit Plan 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 275 calendar year deductible

Benefits Plan pays provides Page
Inpatient Hospital PPO benefit 100 of room board and other charges no deductible 10 11 care Non PPO benefit After a 100 deductible per admission 80 for ward or
semiprivate accommodations 80 of other hospital charges 10
Surgical PPO benefit 85 of the surgeon's negotiated rate Non PPO benefit 70 of reasonable and customary charges 11 12

Medical PPO benefit 85 of the doctor's negotiated rate Non PPO benefit 70 of the doctor's reasonable and customary charges 15 17
Maternity Same benefits as for illness or injury 13 Mental Conditions PPO benefit After a 400 deductible 50 of PPO hospital charges up to
a maximum of 50 days per year Non PPO benefit After a 500 deductible per admission 50 for ward or semiprivate
accommodations and other hospital charges up to a maximum of 50 days per year 14
Substance Abuse After a separate 250 calendar year Substance Abuse deductible 50 of charges for up to 30 days of care while confined in a treatment facility per lifetime 14

Outpatient Hospital PPO benefit 85 of the negotiated rate care Non PPO benefit 70 of reasonable and customary charges 15 17
Surgical PPO benefit 85 of the surgeon's negotiated rate Non PPO benefit 70 of reasonable and customary charges related to and
on the day of surgery 11 12
Medical PPO benefit 15 copay per covered office visit 5 copay per allergy injection 5 25 copay per routine screening service other benefits 85 of the negotiated rate

Non PPO benefit 70 of reasonable and customary charge for outpatient physician office visits 70 of reasonable and customary charges for other medical services 15 17

Maternity Same benefits as for illness or injury 13
Home Health Care No current benefit See page 17 for Skilled nursing care
Mental Conditions PPO benefit After satisfaction of a 250 calendar year deductible 60 of Substance Abuse negotiated rate for 30 visits per year

Non PPO benefit After satisfaction of a 250 calendar year deductible 50 of reasonable and customary charges for 30 visits per year 14

Emergency care 100 for nonsurgical outpatient services and supplies for care of injury when incurred within 48 accidental injury hours after accident charges incurred after 48 hours are considered as Other Medical Benefits 17
Prescription drugs Pharmacy From a Network retail pharmacy after the 25 per individual 50 per family prescription drug deductible you pay a copayment of 5 per generic 10 per name brand per
prescription or refill From a non Network pharmacy after the 25 per individual 50 family drug deductible you pay 40 the Plan pays 60 of covered charges 18 -19
Mail order You pay a copayment of 12 generic and 25 name brand per prescription or refill 18 -19

Dental Care No current benefit
Additional benefits Childhood immunizations Pap smears Skilled nursing care Skilled nursing facility Well child care 17

Protection against PPO benefit Plan pays 100 when PPO out of pocket expenses for Inpatient Hospital Surgical catastrophic costs Maternity and Other Medical Benefits total more than 3,000 per individual or 3,000 per family .27 28
Non PPO benefit Plan pays 100 when non PPO out of pocket expenses for Inpatient Hospital Surgical Maternity Other Medical Benefits and Additional Benefits Skilled nursing
facility only total more than 3,500 per individual or 3,500 per family Whether or not you use PPO providers your share of out of pocket expenses will not exceed 3,500 per individual or
3,500 per family in a calendar year 27 28
Mental Plan pays 100 when out of pocket expenses 50 coinsurance for inpatient mental Conditions conditions reach 8,000 per person in a calendar year but not to exceed the 50 day calendar

year maximum 28

35 35
35 Page 36
2000 Rate Information for
NALC Health 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 postal employee but 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 RI 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 Code Gov't Your Gov't Your USPS Your USPS Your Enrollment Share Share Share Share Share Share Share Share

Self Only 321 78.83 46.87 170.80 101.55 93.06 32.64 93.26 32.44
Self and Family 322 175.97 92.66 381.27 200.76 207.74 60.89 201.02 67.61

36 36

Page Navigation Panel