Pages 1--48 from RI 72-001

Page 1 2
Foreign Service Benefit Plan 2000
A Managed Fee for Service Employee Organization Plan with a Preferred Provider Organization
For changesin benefitssee
page 4
Sponsored by the American Foreign Service Protective Association

Who may enroll in this Plan You must be or become a member of the American Foreign Service Protective Association

To become a member When you enroll in the Foreign Service Benefit Plan you automatically become a member of the Protective Association New membership in the Protective Association is
limited to American Foreign Service personnel and GS direct hire employees working for 1 the Department of State 2 the Agency for International Development 3 the Foreign Commercial
Service 4 the Foreign Agricultural Service and to Executive Branch civilian employees including Department of Defense civilians assigned overseas on a regular tour of duty

GS direct hire employees and Executive Branch civilian employees must enroll in the Health Plan when actively employed in order to retain or choose the Plan in retirement Only annuitants who
are eligible under the Foreign Service Retirement System may enroll under this Plan as annuitants

Membership dues There are no membership dues Membership is for life
Enrollment code for this Plan 401 Self only
402 Self and family

Visit the OPM website at http www opm gov insure
and
this Plan's website at http www afspa org

Authorized for distribution by the
UNITED STATES OFFICE OF
PERSONNEL MANAGEMENT
RI 72 001 1
1 Page 2 3

Foreign Service Benefit Plan 2000
Table of Contents
Introduction 3
Plain language 3
How to use this brochure 3
Section 1 Fee For Service plans 4
Section 2 How we change for 2000 4
Section 3 How to get benefits 5 10
Section 4 What to do if we deny your claim or request for preauthorization 11 12
Section 5 Benefits 13 25
Section 6 How to file a claim 27 28
Section 7 General exclusions Things we don't cover 29
Section 8 Limitations Rules that affect your benefits 30 34
Section 9 Fee for Service facts 35 39
Section 10 FEHB facts 40 42
Inspector General Advisory Stop Healthcare Fraud 43
Index 44
Summary of benefits 46 47
Premiums Back cover

2 2
2 Page 3 4
Foreign Service Benefit Plan 2000
Introduction
Foreign Service Benefit Plan 1716 N Street NW
Washington DC 20036 2902
This brochure describes the benefits you can receive from the Foreign Service Benefit Plan under its contract CS 1062 with the Office of Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law This Plan is

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

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

2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get benefits and how we operate
4 What if we deny your claim or request for preauthorization 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 preauthorization

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

3 3
3 Page 4 5
Foreign Service Benefit Plan 2000
Section 1 Fee for Service plans
Fee for service plans reimburse you or your provider for covered services They do not typically provide or arrange for health care Fee for service plans let you choose your own
physicians hospitals and other health care providers
The FFS plan reimburses you for your health care expenses usually on a percentage basis These percentages as well as deductibles methods for applying deductibles to families and

the percentage of coinsurance you must pay vary by plan The type and extent of covered services 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 This arrangement with health care providers gives you enhanced benefits or limits your out of pocket expenses

Section 2 How we change for 2000
Program wide changes To keep your premium as low as possible OPM has set a maximum PPO benefit of 90 and a maximum non PPO benefit of 85 for Medical Surgical Anesthesia and Delivery

professional services
This year you have a right to more information about this Plan care management our networks facilities and providers

If you have a chronic or disabling condition or are in the second or third trimester of pregnancy and your provider is leaving our PPO network at our request without cause we
will notify you You may continue to receive our PPO level 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 the physician's office
does 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

Changes to this Plan The Plan has expanded the PPO Network Area to include certain areas in the following States California Florida New York Texas and Washington
The Plan has increased benefits for Inpatient Hospital Other Charges from 85 to 90 of reasonable and customary charges for PPO and Outside of PPO Network Area benefits
The Plan has increased benefits for Inpatient Hospital Other Charges for Mental Conditions from 85 to 90 of reasonable and customary charges for PPO and Outside of PPO
Network Area benefits
The Plan has increased the maximum dollar payment for Mental Conditions inpatient doctor visits from 40 to 60 under both the PPO and non PPO benefit

The Plan has increased the maximum dollar payment for Mental Conditions inpatient group therapy from 15 to 30 per session under both the PPO and non PPO benefit
The Plan has increased the maximum dollar payment for Mental Conditions outpatient group therapy from 25 to 40 per session under both the PPO and non PPO benefit
The Plan has increased the maximum charge allowable in Other Medical Benefits under the routine physical examination benefit from 250 to 500 per person per calendar year In
addition the Plan has removed the cervical cancer screening benefit from the routine physical exam benefit and now provides a separate benefit under routine services

The Plan has changed its Prescription Drug Benefits as follows added a Drug Card changed the copayments of the Mail Order Drug Program changed the coinsurance on
drugs purchased from a non participating pharmacy and changed the Medicare waiver of coinsurance and copayments See pages 23 24 for complete details

Your share of the premium will increase by 9.4 for Self Only or 8.8 for Self and Family

4 4
4 Page 5 6
Foreign Service Benefit Plan 2000
Section 3 How to get benefits
How do I keep my health FEHB plans are expected to manage their costs prudently All FEHB plans have cost containment care expenses down measures in place All fee for service plans include two specific provisions in their

benefits packages precertification of all inpatient admissions and the flexible benefits option Some include managed care options such as PPOs to help contain costs In addition this Plan
requires precertification of home health care hospice and skilled nursing facility admissions
You can help As a result of your cooperative efforts the FEHB Program has been able to control premium costs Please keep up the good work and continue to help keep costs down

Precertification Precertification evaluates the medical necessity of proposed admissions and the number of
hospital days required to treat your condition Precertification is also required for home health care hospice and skilled nursing facility admissions under this Plan You are responsible for

ensuring that the precertification requirement is met You or your doctor must check with this Plan before being admitted to the hospital If that doesn't happen this Plan will reduce benefits
by 500 In addition you or your doctor must check with this Plan before being admitted to a hospice or skilled nursing facility or receiving home health care If that doesn't happen this
Plan will pay reduced benefits Be a responsible consumer Be aware of your Plan's cost containment provisions You can avoid penalties and help keep premiums under control by following
the procedures specified on pages 35 and 36 of this brochure
Flexible benefits Under the flexible benefits option the Plan has the authority to determine the most effective option way to provide services The Plan may identify medically appropriate alternatives to traditional
care and coordinate the provision of Plan benefits as a less costly alternative benefit Alternative benefits are subject to ongoing review The Plan may decide to resume regular contract
benefits at its sole discretion Approval of an alternative benefit is not a guarantee of any future alternative benefits The decision to offer an alternative benefit is solely the Plan's and
may be withdrawn at any time It is not subject to OPM review under the disputed claims process

PPO This Plan offers its members in the Washington D C metropolitan and Greater Baltimore area and certain areas of the States of California Florida New York Texas and Washington the
opportunity to reduce out of pocket expenses by choosing facilities and providers who participate in the Plan's Preferred Provider Organization PPO Consider the PPO cost savings when
you review Plan benefits and if you live in these areas check with the Plan to find out which local facilities and providers are PPO providers Check with your doctor to see whether he or
she has admitting privileges at a PPO hospital

How much do I pay for You must share the cost of some services These cost sharing measures include deductibles 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 expenses an individual must incur for covered
services and supplies each calendar year before the Plan pays Other Medical Benefits and outpatient treatment of mental conditions The deductible is 250 per person and 500 per family

Expenses are incurred on the date on which the service or supply is received
Hospital There is a separate deductible of 175 per person per confinement for inpatient hospital room and board expenses for non PPO confinements in the Plan's PPO Network Area and for all
confinements elsewhere Each family member must satisfy this deductible

5 5
5 Page 6 7
Foreign Service Benefit Plan 2000
Section 3 How to get benefits continued
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 There is a separate calendar year deductible of 250 for each person Under a family enrollment the deductible is considered satisfied and benefits are payable for all family members
when the combined covered expenses applied to the deductible for all family members reach 500 during a calendar year

The calendar year deductible is applied only once in a calendar year regardless of how many different illnesses or accidents a person may have Furthermore if two or more covered
members of your family are injured in the same accident you have to pay only one deductible for those members injured in the accident

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

Copayments A copayment is the stated amount the Plan may require you to pay for a covered service such as 10.00 for generic or 20.00 for brand name prescriptions purchased from a participating
pharmacy and 15.00 for generic and 25.00 for brand name prescriptions purchased through the Mail Order Drug Program

If provider waives your If a provider routinely waives does not require you to pay your share of the charge for share services rendered the Plan is not obligated to pay the full percentage of the amount of the
provider's original charge it would otherwise have paid A provider or supplier who routinely waives coinsurance copayments or deductibles is misstating the actual charge This practice may
be in violation of the law The Plan will base its percentage on the fee actually charged For example if the provider ordinarily charges 100 for a service but routinely waives the 20
coinsurance the actual charge is 80 The Plan will pay 64 80 of the actual charge of 80
When hospital charges When inpatient claims are paid according to a Diagnostic Related Group DRG limit for are limited by law instance for admissions of certain retirees who do not have Medicare see page 34 the Plan
will pay 30 of the total covered amount as room and board charges and 70 as other charges and will apply your coinsurance accordingly

Lifetime maximums The Hospice benefit is limited to 7,500 per person per lifetime when the hospice care is precertified
The Hospice benefit is limited to 4,500 per person per lifetime when the hospice care is not precertified
The Orthodontic benefit is limited to 1,000 per person per lifetime
The Substance abuse benefit is limited to two treatment programs per person per lifetime
The Smoking cessation benefit is limited to one per person per lifetime
Diagnosis and treatment of infertility is limited to a maximum benefit of 5,000 per person per lifetime

6 6
6 Page 7 8
Foreign Service Benefit Plan 2000
Section 3 How to get benefits continued
Do I have to submit You do not have to submit claims to us if you use preferred providers When you file a claim claims for non PPO Providers and overseas providers for example please send us all of the documents

for your claim as soon as possible You should submit claims within 90 days after the expense for which the claim being made was incurred but in no event later than 2 years from
the date the expense in question was incurred We can extend this deadline if timely filing was prevented by administrative operations of Government or legal incapacity provided you submit
the claim as soon as reasonably possible
Please see section 6 How to file a claim for specific information you need to know before you file a claim with us

Who provides my health In a Fee for Service Plan you may choose any covered facility or provider care
Covered facilities Birthing center A licensed facility that is equipped and operated solely to provide prenatal care to perform
uncomplicated spontaneous deliveries and to provide immediate postpartum care
Day care center A facility licensed as a day care center and that provides a planned program of psychiatric services for patients with mental conditions who must spend their days but not nights under
psychiatric supervision and that are not for schooling custodial recreational or training services

Hospice A public or private agency or organization that
1 primarily provides inpatient hospice care to terminally ill persons
2 is certified by Medicare as such or is licensed or accredited as such by the jurisdiction it is in

3 is supervised by a staff of M D s or D O s at least one of whom must be on call at all times
4 provides 24 hour a day nursing services under the direction of an R N and has a fulltime administrator and
5 provides an ongoing quality assurance program
Hospital 1 An institution that is accredited as a hospital under the hospital accreditation program of the Joint Commission on Accreditation of Healthcare Organizations JCAHO or

2 Any other institution that is operated pursuant to law under the supervision of a staff of doctors and with 24 hour a day nursing services and that is primarily engaged in providing

a General inpatient care and treatment of sick and injured persons through medical diagnostic and major surgical facilities all of which facilities must be provided on its
premises or under its control or
b Specialized inpatient medical care and treatment of sick or injured persons through medical and diagnostic facilities including X ray and laboratory on its premises

under its control or through a written agreement with a hospital as defined above or with a specialized provider of those facilities

3 For inpatient and outpatient treatment of alcohol and drug abuse the term hospital also includes a free standing alcohol and drug abuse treatment facility approved by the
JCAHO
In no event shall the term hospital include a convalescent nursing home or institution or part thereof that

1 is used principally as a convalescent facility rest facility nursing facility or facility for the aged
2 furnishes primarily domiciliary or custodial care including training in the routines of daily living or
3 is operated as a school
7 7
7 Page 8 9
Foreign Service Benefit Plan 2000
Section 3 How to get benefits continued
Skilled nursing An institution or that part of an institution which provides convalescent skilled nursing care facility 24 hours a day and is classified as a skilled nursing facility under Medicare

Covered providers Covered providers include
Physician Doctors of medicine M D osteopathy D O dental surgery D D S medical dentistry D M D podiatric medicine D P M and optometry O D when acting

within the scope of their licenses or certification are considered physicians
Other covered providers include
Qualified Clinical Psychologist An individual who has earned either a Doctoral or Masters degree in psychology or an allied discipline and who is licensed or certified in the

state where services are performed such as Licensed Professional Counselors
Nurse Midwife A person who is certified by the American College of Nurse Midwives or is licensed or certified as a nurse midwife in states requiring licensure or certification

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

Clinical Social Worker A social worker who 1 has a Masters or Doctoral degree in social work 2 has at least two years of clinical social work practice and 3 in states
requiring licensure certification or registration is licensed certified or registered as a social worker where the services are rendered

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

Audiologist A person who is licensed registered or certified in the state where services are performed

For purposes of this FEHB brochure the term doctor includes all of these providers when the services are performed within the scope of their license or certification

Coverage in medically Within States designated as medically underserved areas any licensed medical practitioner will underserved areas
be treated as a covered provider for any covered services performed within the scope of that license For 2000 the States designated as medically underserved are Alabama Idaho Kentucky

Louisiana Mississippi Missouri New Mexico North Dakota South Carolina South Dakota Utah and Wyoming

PPO arrangements PPO facilities and providers agree to provide service to Plan members at a lesser cost than for
the same service from a non PPO provider Provider networks may be more extensive in some areas than others The availability of every specialty in all areas cannot be guaranteed If no

provider is available or you do not use a PPO provider the standard non PPO benefits apply You must present your PPO Identification Card confirming your PPO participation to be
eligible for PPO benefits
This Plan's PPO The Plan has entered into an arrangement with Mutual of Omaha's Preferred Provider Organization
PPO This is a group of doctors and hospitals in certain areas that have contracted with Mutual to provide medical services at reduced costs Each time you need medical care by

a doctor or hospital you have the choice to use a health care provider who participates in the network or one who doesn't Regardless of the provider you choose benefits will be subject to
all terms conditions and limitations of the Plan In addition the Plan does not supervise control or guarantee the health care services of any preferred provider or other provider When
you phone for an appointment please verify that the physician is still a PPO provider When you visit the provider present your PPO Identification Card confirming your PPO
participation
8 8
8 Page 9 10
Foreign Service Benefit Plan 2000
Section 3 How to get benefits continued
When you use a PPO Enrollees living in the PPO Network Area will receive a PPO Identification Card confirming provider their PPO network participation and a directory of PPO providers Providers who belong to the
network must meet specific criteria including location medical specialty professional skill and proper credentials The Plan will publish an updated list of preferred providers periodically
For the most current list of preferred providers you may contact the Plan The list will show when a preferred provider's participation in the Plan's preferred provider option is limited to

1 a part of a health care facility or
2 the furnishing of certain covered services

The selection of PPO providers is solely the Plan's responsibility continued participation of any specific provider cannot be guaranteed

Enrollees living in the PPO Network Area as defined on the following page may use the PPO network when they get local doctor and or hospital care Subject to the Plan's definitions
limitations and exclusions the Plan pays 100 of covered charges for a semi private room and 90 of other covered hospital charges with no deductible for members who are admitted
to a PPO provider facility 90 of covered charges for a doctor for surgical services and 90 of covered charges in excess of the deductible for services of a doctor other than for surgery
until the member's out of pocket expense equals the catastrophic limit The Plan will then pay 100 of these charges If you live in the PPO Network Area listed on this page access the
PPO directory either through Mutual of Omaha's web site http www mutualofomaha com or as a link through our web site at http www afspa org or call 202 833 4910 for information
concerning the PPO

When you use a Enrollees living in the PPO Network Area who elect to be admitted to a non PPO facility will non PPO provider in be required to pay a 175 per confinement per person deductible The Plan will then pay 80
this area of covered charges for a semi private room and board rate and 85 for other covered hospital charges until the member's out of pocket expense equals the catastrophic limit The Plan will
then pay these charges at 100
If you elect to use the services of a non PPO doctor the Plan will pay 80 of covered charges of a doctor for surgical services and 80 for covered charges in excess of the deductible

for services of a doctor other than for surgery until the member's out of pocket expense equals the catastrophic limit The Plan will then pay 100 of these charges

Outside the Enrollees living outside the PPO Network Area will be required to pay a 175 per admission Network Area
per person deductible if confined in a hospital The Plan will then pay 100 of covered charges for a semi private room and board rate and 90 of other covered hospital charges

until the member's out of pocket expense equals the catastrophic limit The Plan will then pay 100 of these charges

The Plan will pay 90 of covered charges of a doctor for surgical services and 80 for covered charges in excess of the deductible for services of a doctor other than for surgery until
the member's out of pocket expense equals the catastrophic limit The Plan will then pay 100 of these charges

PPO Network Area The PPO Network Area for 2000 consists of Washington D C and certain counties in the
following States

California Florida Maryland New York Texas Virginia Washington

If you live in the counties of these States that are included in the Plan's PPO area the Plan will send you a PPO Identification Card and a PPO Directory You may obtain information on
the Plan's PPO providers by visiting Mutual of Omaha's web site at http www mutualofomaha com or as a link through our web site at http www afspa org or
calling us at 202 833 4910 for information concerning the PPO

9 9
9 Page 10 11
Foreign Service Benefit Plan 2000
Section 3 How to get benefits continued
If you live in these areas and receive services or supplies from any non PPO facility or provider in any of these localities it could result in higher out of pocket costs to you You must

use PPO Providers to receive maximum Plan benefits when you obtain care in the PPO Network Area

Outside the Enrollees living outside the PPO Network Area will be reimbursed by this Plan at regular Plan Network Area benefits

What do I do if I'm in First call our customer service department at 202 833 4910 If you are new to the FEHB the hospital when I join Program we will reimburse your covered expenses If you are currently in the FEHB Program
this Plan and are switching to us your former plan will pay for the hospital stay until
You are discharged not merely moved to an alternative care center or
You exhaust the benefits available from your former plan or
The 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 serious Please contact us if you believe your condition is chronic or disabling If it is you may be illness and my provider able to continue seeing your provider for up to 90 days after you receive notice that we are
leaves the Plan or this terminating our contract with the provider unless the termination is for cause If you are in Plan leaves the Program the second or third trimester of pregnancy you may continue to see your OB GYN until the
end of your postpartum care
You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and you enroll in a new FEHB plan Contact the new plan and explain that you have

a serious or chronic condition or are in 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
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 if a The procedures the Plan follows in determining whether a drug device or biological product is service is experimental or experimental or investigational are explained in the definition below
investigational
Experimental or A drug device or biological product is experimental or investigational if the drug device or investigational biological product cannot be lawfully marketed without approval of the U S Food and Drug

Administration FDA and approval for marketing has not been given at the time it is furnished Approval means all forms of acceptance by the FDA

A medical treatment or procedure or a drug device or biological product is experimental or investigational if 1 reliable evidence shows that it is the subject of ongoing phase I II or III
clinical trials or under study to determine its maximum tolerated dose its toxicity its safety its efficacy or its efficacy as compared with the standard means of treatment or diagnosis or
2 reliable evidence shows that the consensus of opinion among experts regarding the drug device or biological product or medical treatment or procedure is that further studies or
clinical trials are necessary to determine its maximum tolerated dose its toxicity its safety its efficacy or its efficacy as compared with the standard means of treatment or diagnosis

Reliable evidence shall mean only published reports and articles in the authoritative medical and scientific literature the written protocol or protocols used by the treating facility or the
protocol s of another facility studying substantially the same drug device or 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 need additional information regarding the determination of experimental and investigational please contact the Plan

10 10
10 Page 11 12
Foreign Service Benefit Plan 2000
Section 4 What if we deny your claim or request for preauthorization
What should I do before Before you ask us to reconsider your claim you should first check with your provider or facility filing a disputed claim to be sure that the claim was filed correctly For instance did the provider use the correct

procedure code for the services performed surgery laboratory test X ray office visit etc Have your provider indicate any complications of any surgical procedures performed Your
provider should include copies of an operative or procedure report or other documentation that supports your claim

If we deny your request for preauthorization 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 preauthorization or
4 Ask for more information

If we ask your medical provider for more information we will send you a letter advising you of this request We must make a decision within 30 days after we receive the additional information

If we do not receive the requested information within 60 days we will make our decision based on the information we already have

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

What if I have a serious or Call us at 202 833 4910 and we will expedite our review life threatening condition
and you haven't responded to my request for
preauthorization
What if you have denied If we expedite your review due to a serious medical condition and deny your request we will my request for inform OPM so that they can give your claim expedited treatment too Alternatively you can

preauthorization and my call OPM's health benefits Contract Division II at 202 606 3818 between 8 a m and 5 p m condition is serious or life Serious or life threatening conditions are ones that may cause permanent loss of bodily functions
threatening or death if they are not treated as soon as possible

Are there other time You must write to OPM and ask them to review our decision within 90 days after we uphold limits our initial denial or refusal You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your request within 120 days of the date you asked us to reconsider your claim
2 You provided us with the 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

11 11
11 Page 12 13
Foreign Service Benefit Plan 2000
Section 4 What if we deny your claim or request for preauthorization continued
What do I send to OPM Your request must be complete or OPM will return it to you You must send the following information

1 A statement about why you believe our decision is wrong based on specific benefit provisions in this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call

If you want OPM to review different claims you must clearly identify which documents apply to which claim

Who can make the Those who have a legal right to file a disputed claim with OPM are request
1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled person's representative They must send a copy of the person's specific written consent with

the review request

Where should I mail my Send your request for review to Office of Personnel Management Office of Insurance disputed claim to OPM Programs Contracts Division II P O Box 436 Washington D C 20044

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

What laws apply if Federal law governs your lawsuit benefits and payment of benefits The Federal court will I file a lawsuit base its review on the record that was before OPM when OPM made its decision on your
claim You may recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment services supplies or drugs covered by us until you have completed the OPM review

procedure described above

Your records and the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from Privacy Act you and 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

12 12
12 Page 13 14
Foreign Service Benefit Plan 2000
Section 5 Benefits
Inpatient Hospital Benefits
What is covered The Plan pays for inpatient hospital services as shown below

Precertification The medical necessity of your hospital admission must be precertified for you to receive full Plan benefits Emergency admissions not precertified must be reported within two business
days following the day of admission even if you have been discharged Otherwise the benefits payable will be reduced by 500 See pages 35 and 36 for details

Waiver This precertification requirement does not apply to persons whose primary coverage is Medicare Part A or another health insurance policy or when the hospital admission is outside the
United States For information on when Medicare is primary see page 31
Room and board Semiprivate ward and intensive care accommodations including general nursing care meals and special diets are covered If a private room is used only the hospital's average semiprivate
room rate will be considered a covered expense However if the patient's isolation is required to prevent contagion to others the charge for a private room will be covered

PPO Benefits If you live in the PPO Network Area
The Plan pays 100 of semiprivate room and board charges
Non PPO Benefits If you live in the PPO Network Area
After a 175 inpatient hospital deductible per person per confinement is satisfied the Plan pays 80 of semiprivate room and board charges

Outside the PPO After the 175 inpatient hospital deductible per person per confinement the Plan pays 100 Network Area of semiprivate room and board charges
Other charges The Plan pays the applicable percent shown below of reasonable and customary charges for all covered hospital charges other than room and board including services and supplies received
while in a hospital These include but are not limited to
Use of operating room
Surgical dressings
Drugs and medications for use in the hospital
X ray and laboratory examinations
Blood or blood plasma if not donated or replaced and its administration and
Inpatient private duty nursing services by an R N or L P N when the services are rendered outside of North America

PPO Benefits If you live in the PPO Network Area
The Plan pays 90 of reasonable and customary charges
Non PPO Benefits If you live in the PPO Network Area

The Plan pays 85 of reasonable and customary charges
Outside the PPO The Plan pays 90 of reasonable and customary charges Network Area

13 13
13 Page 14 15
Foreign Service Benefit Plan 2000
Section 5 Benefits continued
Limited benefits Pre admission testing The Plan pays 100 of reasonable and customary charges for preadmission tests received
within 72 hours before admission to a hospital
Hospitalization for Hospital charges are covered when a nondental physical impairment exists that makes hospitalization dental work necessary to safeguard the health of the patient even though no benefits may be payable
for services of dentists or doctors in connection with the dental treatment See page 25 for dental services covered by the Plan

Related benefits Mental conditions Charges for hospital expenses for treatment of mental conditions are not covered under Inpatient
Hospital Benefits Coverage for treatment of mental conditions is discussed on pages 18 and 19

Professional charges Charges for professional services of a doctor or any other practitioner covered under this Plan even though billed by a hospital as part of hospital services are covered only under Surgical
Benefits Maternity Benefits Mental Conditions Substance Abuse Benefits Other Medical Benefits or Additional Benefits pages 14 22

Skilled nursing facility Benefits provided are covered under Additional Benefits see page 23
Prosthetic appliances Prosthetic appliances e g pacemakers artificial hips intraocular lenses are covered only under Other Medical Benefits page 20

Take home items Drugs medical supplies medical equipment and any covered items billed by a hospital but to be used at home are covered under Other Medical Benefits page 20
What is not covered Confinement in nursing homes rest homes places for the aged convalescent homes or any place that is not a hospital skilled nursing care facility or hospice see Facilities and Other
Providers on pages 7 and 8
Custodial care as defined on page 38 even when provided by a hospital
A hospital admission that is not medically necessary i e the medical services did not require the acute hospital inpatient overnight setting but could have been provided in a

doctor's office the outpatient department of a hospital or some other setting without adversely affecting the patient's condition or the quality of medical care rendered

Inpatient private duty nursing except as provided on the previous page
Personal comfort items such as radio television telephone beauty and barber services ID tags baby beads footprints guest cots guest meals newspapers and similar items

Surgical Benefits What is covered The Plan pays for the following services
Hospital inpatient PPO Benefit If you live in the PPO Network Area

The Plan pays 90 of reasonable and customary charges for surgery
Non PPO Benefit If you live in the PPO Network Area
The Plan pays 80 of reasonable and customary charges for surgery

Outside the PPO The Plan pays 90 of reasonable and customary charges for surgery Network Area
Benefit

14 14
14 Page 15 16
Foreign Service Benefit Plan 2000
Section 5 Benefits continued
Outpatient PPO Benefit
If you live in the PPO Network Area

The Plan pays 90 of reasonable and customary charges for surgery The Plan also pays 90 reasonable and customary charges by a hospital physician or approved surgicenter for outpatient

services and supplies furnished within 72 hours of an outpatient surgical operation Laboratory tests tissue pathology and supplies in relation to office surgery are also covered
under this benefit except as shown on page 16
Outside the PPO The Plan pays 90 of reasonable and customary charges for surgery The Plan also pays 90 Network Area reasonable and customary charges by a hospital physician or approved surgicenter for outpatient
Benefit services and supplies furnished within 72 hours of an outpatient surgical operation Laboratory tests tissue pathology and supplies in relation to office surgery are also covered
under this benefit except as shown on page 16

Multiple surgical When multiple or bilateral surgical procedures that add time or complexity to patient care are procedures performed during the same operative session the Plan pays as follows the value of the major
procedure plus 50 of the value of the lesser procedure s
Incidental When an incidental procedure e g incidental appendectomy lysis of adhesions excision of procedures scar is performed through the same incision the reasonable and customary allowance will be
that of the major procedure only
Assistant surgeon Charges by an assistant surgeon in connection with inpatient or outpatient surgery are covered inpatient outpatient at 80 of reasonable and customary charges based on 20 of the reasonable and customary
charge allocated to the surgeon when determined by the Plan to be medically necessary
Anesthesia PPO Benefit If you live in the PPO Network Area

The Plan pays 90 of reasonable and customary charges for general administration of anesthesia in or out of a hospital

Non PPO Benefit If you live in the PPO Network Area
The Plan pays 80 of reasonable and customary charges for general administration of anesthesia in or out of a hospital

Outside the PPO The Plan pays 90 of reasonable and customary charges for general administration of Network Area anesthesia in or out of a hospital
Organ tissue All reasonable and customary charges incurred for a covered surgical transplant whether transplants and incurred by the recipient or donor will be considered expenses of the recipient and will be
donor expenses covered the same as for any other illness or injury This benefit applies only if the recipient is covered by the Plan

Transplant surgery means transfer of a body organ s from the donor to the recipient
Recipient means an insured person who undergoes a surgical operation to receive a body organ s transplant

Donor means a person who undergoes a surgical operation for the purpose of donating a body organ s for transplant surgery
15 15
15 Page 16 17
Foreign Service Benefit Plan 2000
Section 5 Benefits continued
What is covered Cornea heart kidney liver pancreas heart lung single lung and double lung transplants
Bone marrow and stem cell support as follows
Allogeneic bone marrow transplants
Autologous bone marrow transplants autologous stem cell support and autologous peripheral stem cell support for 1 acute lymphocytic or non lymphocytic leukemia 2

advanced Hodgkin's lymphoma 3 advanced non Hodgkin's lymphoma 4 advanced neuroblastoma 5 testicular mediastinal retroperitoneal and ovarian germ cell tumors 6 breast
cancer 7 multiple myeloma and 8 epithelial ovarian cancer
Related medical and hospital expenses of the donor are covered when the recipient is covered by the Plan

What is not Transplants not listed as covered services or supplies for or related to surgical transplant covered procedures for artificial or human organ transplants not listed as covered
Oral and maxillofacial Charges of an oral surgeon D D S or D M D for removal of impacted teeth or for a surgery nondental surgical operation performed on the jaw or in the mouth will be covered as shown
on pages 14 and 15 Oral surgery that involves any tooth or tooth structure alveolar process abscess periodontal disease or disease of gingival tissue is not covered by the Plan except as
provided under Dental Benefits see page 25
Mastectomy Surgery Women who undergo mastectomies may at their option have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure

Benefits will be provided for breast reconstruction surgery following a mastectomy including surgery to produce a symmetrical appearance on the other breast Benefits will be provided for
all stages of breast reconstruction following a mastectomy including treatment of any physical complications including lymphedemas and for breast prostheses including surgical bras and
replacements Breast prostheses are covered under Other Medical Benefits See page 20
Related benefits Prosthetic appliances Prosthetic appliances e g pacemakers artificial hips intraocular lenses are covered only
under Other Medical Benefits page 20
Second opinion Charges of an independent consulting doctor are covered under Other Medical Benefits see voluntary page 20

Take home items Drugs medical supplies medical equipment and any covered items billed by a hospital physician or approved surgicenter but to be used at home are covered under Other Medical Benefits
page 20
What is not covered Cosmetic surgery as defined on page 38 except for the repair of accidental injuries sustained while covered under the FEHB Program to correct a congenital anomaly or for the
reconstruction of a breast following a mastectomy
Radial keratotomy
Treatment or removal of corns and calluses or trimming of toenails

16 16
16 Page 17 18
Foreign Service Benefit Plan 2000
Section 5 Benefits continued
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 cesarean delivery Inpatient stays
will be extended if medically necessary
Inpatient hospital Precertification The medical necessity of your hospital admission must be precertified for you to receive full

Plan benefits Unscheduled or emergency admissions not precertified must be reported within two business days following the day of admission even if you have been discharged Newborn
confinements that extend beyond the mother's discharge must also be precertified If any of the above are not done the benefits payable will be reduced by 500 See pages 35 and 36 for details

Waiver See page 35 for exceptions to the precertification requirement
Room and Board PPO Benefits If you live in the PPO Network Area

The Plan pays 100 of semiprivate room and board charges
Non PPO If you live in the PPO Network Area Benefits
After a 175 inpatient hospital deductible per person per confinement the Plan pays 80 of semiprivate room and board charges

Outside the PPO After the 175 inpatient hospital deductible per person per confinement the Plan pays 100 Network Area of semiprivate room and board charges
Other Charges PPO Benefits
If you live in the PPO Network Area

The Plan pays 90 of reasonable and customary charges for all other covered hospital charges including anesthesia supplies and ambulance

Non PPO If you live in the PPO Network Area Benefits
The Plan pays 85 of reasonable and customary charges for all other covered hospital charges including anesthesia supplies and ambulance

Outside the PPO The Plan pays 90 of reasonable and customary charges for all other covered hospital Network Area
charges including anesthesia supplies and ambulance

Obstetrical care Bassinet or nursery charges for days on which mother and child are both confined are considered expenses of the mother and not expenses of the child Charges that are considered
expenses of the child are paid only if the child is covered by a family enrollment Routine circumcision is covered under Surgical Benefits for a newborn child covered by a family
enrollment pages 14 and 15

Outpatient care Charges of the doctor and or State licensed midwife for delivery prenatal and postnatal visits
and amniocentesis are paid under Surgical Benefits pages 14 and 15

The Plan pays 100 of reasonable and customary charges not subject to the calendar year or inpatient hospital deductibles for covered facility services at the time of delivery when delivery

is on an outpatient basis delivery is at a licensed birthing center or inpatient delivery results in a hospital confinement of one day overnight or less and no more than one day's
room and board charge
If the mother or newborn child is transferred from a birthing center to a hospital due to medical complications the birthing center expenses will be paid as shown above For a confinement of

one day overnight or less if the mother and child leave the hospital against medical advice this benefit is not payable and regular Plan benefits will apply

17 17
17 Page 18 19
Foreign Service Benefit Plan 2000
Section 5 Benefits continued
Related benefits Diagnosis and treatment Diagnosis and treatment of infertility are covered as Other Medical Benefits page 21

of infertility
Testing Sonograms other related tests on the unborn child and the initial examination of a newborn child are covered as Other Medical Benefits page 20

Voluntary sterilization Voluntary sterilization is covered under Surgical Benefits pages 14 15
Well child care Well child visits to a doctor for children up to age 18 months are covered as Other Medical Benefits page 20 Childhood immunizations are covered as Additional Benefits page 22

For whom Benefits are payable under Self Only enrollments and for family members under Self and Family enrollments
What is not covered Reversal of voluntary surgical sterilization
Routine sonograms to determine fetal age and or size
Procedures services drugs and supplies related to impotency sex transformations sexual dysfunction or sexual inadequacy

Assisted Reproductive Technology ART procedures such as artificial insemination in vitro fertilization embryo transfer and gamete intrafallopian transfer GIFT as well as
services and supplies related to ART procedures
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
The standard benefits of this Plan apply for the out of network area PPO benefits are available only in the PPO Network Area and apply only when you use a PPO Provider If you live in the PPO area and do not use a PPO provider non PPO

benefits apply
Mental Conditions Substance Abuse Benefits
What is covered The Plan pays for the following services Mental conditions

Inpatient care The Plan pays this the same as Inpatient Hospital Benefits including Other charges see page 13 Catastrophic protection benefit applies to your covered out of pocket expenses for the
treatment of mental conditions see pages 36 and 37
Precertification The medical necessity of your admission to a hospital or other facility must be precertified for you to receive full Plan benefits Emergency admissions must be reported within two business

days following the day of admission even if you have been discharged Otherwise the benefits payable will be reduced by 500 See pages 35 and 36 for details

Waiver See page 35 for exceptions to the precertification requirement
Inpatient visits PPO Benefits If you live in the PPO Network Area

The Plan pays 90 of reasonable and customary charges for doctors in hospital visits for mental conditions up to a maximum Plan payment of 60 per visit with a limit of 50 visits per
calendar year
In addition benefits for group therapy are payable at actual charges up to a maximum of 30 per session Group therapy is not subject to the calendar year visit limitation

Non PPO If you live in the PPO Network Area or Out of Network Area Benefits
The Plan pays 80 of reasonable and customary charges for doctors in hospital visits for mental conditions up to a maximum Plan payment of 60 per visit with a limit of 50 visits per

calendar year
In addition benefits for group therapy are payable at actual charges up to a maximum of 30 per session Group therapy is not subject to the calendar year visit limitation

Charges for professional services of a doctor or any other practitioner covered under this Plan even though billed by a hospital as part of hospital services are covered only as specified above

18 18
18 Page 19 20
Foreign Service Benefit Plan 2000
Section 5 Benefits continued
Outpatient care
PPO Benefits If you live in the PPO Network Area

After the 250 calendar year deductible the Plan covers outpatient care by a doctor clinical psychologist clinical social worker psychiatric nurse or a nurse practitioner clinical specialist

The Plan pays 90 of reasonable and customary charges limited to 60 therapy visits per person per calendar year for individual visits including collateral visits if the patient is a child

The Plan pays 90 of reasonable and customary charges up to a maximum of 40 per session for group therapy visits Group therapy is not subject to the calendar year visit limitation

Non PPO If you live in the PPO Network Area or Out of Network Area Benefits
After the 250 calendar year deductible the Plan covers outpatient care by a doctor clinical psychologist clinical social worker psychiatric nurse or a nurse practitioner clinical specialist

The Plan pays 75 of reasonable and customary charges limited to 60 therapy visits per person per calendar year for individual visits including collateral visits if the patient is a child

The Plan pays 75 of reasonable and customary charges for day care in a day care center limited to 20 visits per person per calendar year provided the institution meets the definition
on page 7
The Plan pays 50 of reasonable and customary charges up to a maximum of 40 per session for group therapy visits Group therapy is not subject to the calendar year visit limitation

Charges for psychological testing and pharmacological visits are covered only under Other Medical Benefits see page 20 The medical management of mental conditions will be covered
under this Plan's Other Medical Benefits provisions Related drug costs will be covered under this Plan's Prescription Drug Benefits Office visits for the medical aspects of treatment do not
count toward the Plan's visits per person per calendar year maximums

Substance abuse The Plan will pay regular Inpatient Hospital Benefits refer to page 13 and Other Medical Benefits refer to page 20 for up to 5 days confinement each calendar year for detoxification
in a hospital or an accredited treatment center with detoxification facilities
The Plan also pays 100 of charges up to 8,000 for one 28 day inpatient substance abuse treatment program in an accredited alcoholic or drug treatment facility per person per calendar

year This benefit also includes an aftercare outpatient treatment program that immediately follows the 28 day inpatient program

Precertification Precertification is required to obtain the above benefits for detoxification and or treatment of substance abuse Refer to pages 35 and 36 for additional information on how to obtain
precertification

Lifetime maximum The Substance abuse benefit is limited to two treatment programs per person per lifetime Withdrawal prior to completion constitutes use of one program No other Plan benefits are
available for the treatment of alcoholism or drug addiction with the exception of the detoxification benefit shown above

What is not covered Counseling or therapy for marital educational sexual or behavioral problems

19 19
19 Page 20 21
Foreign Service Benefit Plan 2000
Section 5 Benefits continued
Other Medical Benefits What is covered
PPO Benefits If you live in the PPO Network Area
After the 250 calendar year deductible has been met the Plan pays 90 of covered reasonable and customary charges for the following

Non PPO Benefits If you live in the PPO Network Area and Out of Network Area
After the 250 calendar year deductible has been met the Plan pays 80 of covered reasonable and customary charges for the following

Doctors visits in hospital home office and consultations
Charges by an independent consulting doctor for services in relation to a second opinion regarding the necessity for anticipated surgery

Services of a registered physical therapist or a registered occupational therapist practicing within the scope of the license for administration of therapy in accordance with a doctor's
specific instructions as to type frequency and duration
Speech therapy provided by a licensed speech therapist practicing within the scope of the license but only when necessary to restore speech when there has been a functional loss of

speech due to illness or injury and when therapy is rendered in accordance with a doctor's specific instructions as to type frequency and duration
Well child visits through 18 months of age immunizations are covered under Additional Benefits page 22
One pair of eyeglasses or contact lenses per incident if required to correct an impairment directly caused by accidental ocular injury or specifically ordered by the doctor in connection
with a diagnosis of cataract keratoconus or glaucoma
X ray services and laboratory tests
Blood or blood plasma not donated or replaced
Acupuncture performed by an M D or D O
Radium or radioactive isotopes
Artificial eyes or limbs required to replace natural eyes and limbs
Casts splints trusses braces or crutches
Hospital outpatient services and supplies not covered under any other provision of this Plan
Rental up to the purchase price or purchase at the option of the Plan of durable medical equipment such as wheelchair hospital type bed and iron lung

Oxygen and equipment for its administration
Chemotherapy
Radiation therapy
Ambulance service to or from the hospital
Prescription drugs purchased from a pharmacy outside of the 50 United States see Prescription Drug Benefits page 24 for details

Prescriptions obtained from a doctor or other covered facility
Dental work necessitated by accidental injury to the jaw or sound natural teeth if the accident occurs while covered by the Plan and the service is rendered while covered by this Plan

within 24 months of the accident including expenses of necessary dental X rays and initial replacement of sound natural teeth
Psychological tests and pharmacological visits
Breast prostheses including surgical bras and replacements following a mastectomy
Routine physical examination limited to a maximum charge of 500 per person per calendar year Routine mammograms are covered separately as follows

Routine services In addition to coverage above of diagnostic X rays laboratory and pathology services and machine diagnostic tests the following routine screening services are covered as preventive care
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
From age 40 through 64 one mammogram screening every calendar year and
At age 65 and older one mammogram screening every two consecutive calendar years 20 20
20 Page 21 22
Foreign Service Benefit Plan 2000
Section 5 Benefits continued
Cervical cancer Annual coverage of one pap smear for women age 18 and older screening

Colorectal cancer Annual coverage of one fecal occult blood test for members age 40 and older screening
One screening sigmoidoscopy every five years for members age 50 and older

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

Also covered as From age 19 through 64 one nonfasting total blood cholesterol test every three consecutive Routine services
calendar years are the following
At age 19 and over one tetanus diphtheria Td booster every 10 consecutive calendar years
At age 65 and over one influenza vaccine and pneumococcal vaccine every calendar year

Limited benefits Smoking cessation After satisfaction of the calendar year deductible the Plan will pay up to 100 for enrollment

benefit in one smoking cessation program per member per lifetime
This benefit includes FDA approved drugs and medicines that are intended to aid in smoking cessation Smoking cessation drugs and medications are not available under any other Plan

provisions
Diagnosis and After the 250 calendar year deductible the Plan pays 80 of reasonable and customary treatment of infertility charges up to 5,000 per person per lifetime for the diagnosis and treatment of infertility as
defined below
Diagnosis of infertility includes
The initial diagnostic tests and procedures done solely to identify the cause or causes of the inability to conceive

Treatment of infertility includes
Hormone therapy and related services and
Medical or surgical services performed solely to create or enhance the ability to conceive

Hormone therapy to diagnose or treat infertility is not available under any other Plan provisions

What is not covered Sun or heat lamps whirlpool baths heating pads air purifiers humidifiers air conditioners exercise devices and other items that do not meet the definition of durable medical equipment
Orthopedic shoes orthotics and other supportive devices for the feet
Provocative food testing end point titration techniques and sublingual allergy desensitization
Routine eye examinations
Eyeglasses and contact lenses except as shown on page 20
Eye exercises and visual training orthoptics
Hearing aids and examinations for them except the initial exam
Inpatient private duty nursing except as shown on page 13
Chelation therapy except for acute arsenic gold mercury or lead poisoning
Services provided by a chiropractor except see page 8 regarding medically underserved areas

Drugs and services for cosmetic purposes
Jobst stockings unless determined to be medically necessary by the Plan
Assisted Reproductive Technology ART procedures such as artificial insemination in vitro fertilization embryo transfer and gamete intrafallopian transfer GIFT as well as

services and supplies related to ART procedures are not covered
Telephone consultations
Prescriptions purchased from a non participating pharmacy in the 50 United States except as shown under Prescription Drug Benefits see page 24

Procedures services drugs and supplies related to impotency sex transformations sexual dysfunction or sexual inadequacy

The standard benefits of this Plan apply for the out of network area PPO benefits are available only in the PPO Network Area and apply only when you use a PPO Provider If you live in the PPO area and do not use a PPO provider non PPO
benefits apply 21 21
21 Page 22 23
Foreign Service Benefit Plan 2000
Section 5 Benefits continued
Additional Benefits Accidental injury The Plan pays 100 of reasonable and customary charges made by a hospital or doctor for
outpatient emergency treatment with or without surgery rendered within 72 hours after an accidental injury see definition Charges for services after 72 hours are covered under Other
Medical Benefits Emergency treatment is otherwise covered the same as nonemergency treatment

Childhood Childhood immunizations recommended by the American Academy of Pediatrics are covered at immunizations 100 of reasonable and customary charges for covered members under age 22 Associated
charges for office visits and other services will be considered under Other Medical Benefits See page 20

Emergency ambulance The Plan pays 100 up to 50 for ambulance service within 72 hours of an accident Charges service over 50 for ambulance service are payable under Other Medical Benefits
Home health care When precertification is obtained see pages 35 and 36 the Plan pays 100 of reasonable and customary charges up to 80 per visit for a maximum of 90 home health care visits per calendar
year limited to one visit per day if such care is an alternative to hospitalization
When precertification is not obtained the Plan pays 100 of reasonable and customary charges up to 40 per visit for a maximum of 40 home health care visits per calendar year limited to

one visit per day if such care is an alternative to hospitalization
A home health care visit consists of one of the following
Less than an 8 hour shift of nursing care provided on a part time basis by a registered nurse RN or a licensed practical nurse LPN

One session of physical occupational or speech therapy provided by a licensed therapist
One visit from a licensed social worker limited to two visits per calendar year or
Less than an 8 hour shift of a home health aide's services that are performed under the supervision of a registered nurse RN and that consists mainly of medical care and therapy

provided solely for the care of the insured person
The above home health care services must be furnished by a home health agency or by visiting nurses where services of a home health agency are not available in accord with a home

health care plan see definition certified by the member's doctor and in the insured person's home

Hospice care When precertification is obtained see pages 35 and 36 the Plan pays 100 of reasonable and customary charges up to a maximum of 7,500 for hospice care provided by a hospice agency
or organization see definition to a terminally ill patient in the final stages of illness when such care is recommended by a doctor

When precertification is not obtained the Plan pays 100 of reasonable and customary charges up to a maximum of 4,500 for hospice care when the above requirements are met
This benefit does not apply to services shown as covered under any other provisions of this Plan

Private duty nursing For services rendered by a registered nurse RN or licensed practical nurse LPN in the home at home the Plan will cover up to 500 units per calendar year One private duty nursing unit consists of
up to one hour of private duty nursing care The Plan pays 12 per unit and no deductible applies

Renal dialysis The Plan pays 100 of reasonable and customary charges for all covered services and supplies for renal dialysis in or out of a hospital

22 22
22 Page 23 24
Foreign Service Benefit Plan 2000
Section 5 Benefits continued
Skilled nursing facilities When precertification is obtained see pages 35 and 36 if a person is confined in a skilled nursing facility see definition the Plan will for a maximum of 60 days per confinement pay
100 of reasonable and customary charges when
the confinement is for the purpose of receiving medical care
the confinement is under the supervision of a doctor and
the confinement is an alternative to hospitalization

When precertification is not obtained the Plan will for a maximum of 30 days per confinement pay 80 of reasonable and customary charges in a skilled nursing facility provided the
above conditions are met
Skilled nursing facility benefits shown above will be restored for each new period of confinement There is a new period of confinement when

the requirements listed above are met and
at least 60 days have elapsed since the insured person was last confined in a skilled nursing facility

Prescription Drug Benefits What is covered You may purchase the following medications and supplies prescribed by a doctor from either a
pharmacy or by mail
Drugs that by Federal law of the United States require a doctor's prescription for their purchase

Insulin
Needles and syringes for the administration of covered medications
Diabetic colostomy and ostomy supplies
FDA approved drugs prescriptions and devices for birth control requiring a doctor's prescription

What is not covered Nonprescription medicines over the counter medication Drugs and supplies for cosmetic purposes
Nutritional supplements and vitamins
Medication that under Federal law does not require a prescription even if your doctor prescribes it or State law requires it or for which there is a non prescription equivalent available

Drugs to aid in smoking cessation except those limited to the 100 lifetime maximum as part of the smoking cessation benefit see page 21 You may not obtain smoking cessation
drugs with your PAID Prescription Card or through the Mail Order Drug Program You must purchase these drugs and file the claim with the Plan

Hormone therapy to diagnose or treat infertility except that limited to the 5,000 lifetime maximum as part of the diagnosis and treatment of infertility benefit see page 21 You
may not obtain hormone therapy treatment with your PAID Prescription Card or through the Mail Order Drug Program

Drugs and supplies related to impotency sex transformations sexual dysfunction or sexual inadequacy

From participating The Plan will provide you with a combination Foreign Service Benefit Plan PAID pharmacies in the 50 Prescription identification card In most cases you simply present the card together with the
United States prescription to a participating pharmacy You may purchase up to a 30 day supply of medication You pay a 10.00 copayment for each generic or a 20.00 copayment for each brand
name prescription drug supply or refill No deductible applies Refills cannot be obtained until 75 of the drug has been used You may not obtain more than a 30 day supply through the
pharmacy arrangement You must obtain more than 30 days supply through the Mail Order Drug Program

23 23
23 Page 24 25
Foreign Service Benefit Plan 2000
Section 5 Benefits continued
You may fill your prescription at any pharmacy participating in the PAID TelePAID system You may obtain the names of participating pharmacies by calling 1 800 251 7682 or on the
internet at http www merck medco com or as a link through our web site at http www afspa org Each participating pharmacy has a TelePAID system that calculates your copayment The
Pharmacist receives an electronic message displaying the correct amount to charge you You will be required to sign a signature log to prove you have received the prescription drug You
do not file a PAID prescription card claim with the Plan
When Medicare Part B is the primary payer the Plan does not waive the copayment applicable to covered drugs and supplies purchased at a participating pharmacy

From non participating After the calendar year deductible of 250 is met the Plan pays 50 of reasonable and pharmacies in the 50 customary charges Claims for prescription drugs and medicines that are purchased from a nonparticipating
United States pharmacy in the 50 United States must include receipts that show the name of patient prescription number names of drugs and medicines name of the prescribing doctor
name of pharmacy date and the charge Use the Plan's claim form to claim benefits for prescription drugs and supplies you purchased through a non participating pharmacy in the 50
United States You may obtain claim forms by calling 202 833 4910 Mail claims to the Plan's address on page 28

Waiver When Medicare Part B is the Primary payer the Plan waives the 250 calendar year deductible The Plan does not waive the 50 coinsurance applicable to covered drugs and supplies
purchased at a non participating pharmacy

From pharmacies After the 250 calendar year deductible is met the Plan pays 80 of reasonable and customary outside of the charges Claims for prescription drugs and medicines that are purchased from a pharmacy
50 United States outside of the 50 United States must include receipts that show the name of patient prescription number names of drugs and medicines name of the prescribing doctor name of pharmacy date
and the charge Use the Plan's claim form to claim benefits for prescription drugs and supplies you purchased through a retail pharmacy outside of the 50 United States You may obtain claim
forms by calling 202 833 4910 Mail claims to the Plan's address on page 28

By mail For long term prescription needs use the Mail Order Drug Program to receive higher benefits
If your doctor orders more than a 30 day supply of drugs or covered supplies up to a 90 day supply order your prescription or refill by mail Merck Medco Rx Services will fill your

prescription All drugs and supplies listed on the previous page are covered except for those that require constant refrigeration are too heavy to mail or that must be administered by
physicians in a clinical setting
If a Federally approved generic equivalent to the prescribed drug is available Merck Medco Rx Services will dispense the generic equivalent instead of the name brand unless your doctor

specifies that the name brand is required
You pay a 15.00 copayment for each generic prescription drug supply or refill you purchase by mail You pay a 25.00 copayment for each name brand prescription drug supply or refill

you purchase by mail No deductible applies

When Medicare Part B is the primary payer the Plan does not waive the copayment applicable to covered drugs and supplies purchased through the Mail Order Program

To order your The Plan will send you information on Merck Medco Rx Services To order by mail prescriptions by mail
1 Complete the initial mail order form
2 Enclose your prescription and copayment
3 Mail your order to Merck Medco Rx Services and
4 Allow approximately two weeks for delivery

24 24
24 Page 25 26
Foreign Service Benefit Plan 2000
Section 5 Benefits continued
You'll receive forms for refills and future prescription orders each time you receive drugs or supplies under this program You may also order refills over the Internet directly from Merck

Medco Rx Services at their website http www merck medco com In the meantime if you have any questions about a particular drug or a prescription and to request your first order
forms you may call toll free In the United States 1 800 251 7682 from overseas 1 800 497 4641 available in over 140 countries If you cannot use the overseas 800 number call Merck
Medco collect at 1 973 560 6100
Drugs from other Prescription drugs are also covered under this Plan when they are provided to you by a doctor sources or facility as specified under Other Medical Benefits see page 20

Dental Benefits What is covered The Plan will pay 100 of charges of a dentist D D S or D M D up to the amounts shown
for the following dental services The Plan will pay dental benefits for the listed procedures only

Dental care Preventive care limited to two services per person per calendar year
Oral exam 13
Prophylaxis cleaning adult 23
Prophylaxis child thru age 14 16
Prophylaxis with fluoride child thru age 14 26

Surgery Apicoectomy tooth root amputation 50 per root Alveolectomy excision of alveolar bone
4 through 12 teeth 40 13 through 20 teeth 60
21 or more teeth 80 Alveolar abscess incision and drainage 10
Gingivectomy excision of gum tissue each quadrant 50
Orthodontic services Plan pays 50 of reasonable and customary charges for orthodontic services up to 1,000 per person in a lifetime Orthodontics for purposes of this benefit is the realignment of natural
teeth or correction of malocclusion
Related benefits Oral surgery For covered oral surgery including the removal of impacted teeth see page 16

Accidental injury Dental work required due to accidental injury to sound natural teeth is covered as described to sound natural under Other Medical Benefits if the member was covered by this Plan when the accident
teeth occurred see page 20
What is not covered Other dental services including dental implants not listed as covered
Any other expenses for covered dental services except as shown above and except for hospitalization when required are not covered under any other provision of this Plan

Treatment of temporomandibular joint TMJ disorders except as provided on page 16 under Oral and maxillofacial surgery

The standard benefits of this Plan apply for the out of network area PPO benefits are available only in the PPO Network Area and apply only when you use a PPO Provider If you live in the PPO area and do not use a PPO provider non PPO
benefits apply
25 25
25 Page 26 27
Non FEHB Benefits Available to Plan Members The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are
made available to all enrollees and family members of this Plan The cost of the benefits described on this page is not included in the FEHB premium and any charges for these services do not count toward any FEHB deductibles out of pocket
maximum copay charges etc These benefits are not subject to the FEHB disputed claims review procedure
Long Term Long Term Care is open to AFSPA members under the age of 80 Premium rates are based on your age at
Care the time of acceptance into the program The program Covers confinements for skilled nursing intermediate nursing and custodial care 100 per day benefit

Covers confinement in an Assisted Living Facility 50 per day benefit Covers nonconfinement care for home health care adult day care and respite care 50 per day benefit

Contains return of premium feature Contains benefit increase option
Contains optional automatic inflation protection rider
Term Life Term Life Insurance is open to all AFSPA members until age 60 The program includes
Insurance Up to 200,000 of coverage Living Care Benefit that allows early access to a portion of your life insurance benefit in certain cases

Coverage for death including acts of terrorism or declared or undeclared war
Expanded Expanded Dental benefit programs are open to every AFSPA member We offer two different plans one Dental that is available in the D C metropolitan area and one that is available overseas and anywhere in the U S

Benefits The plans cover services such as fillings X rays crowns root canals and preventive care Premiums are based on self only two party or family enrollment and may be paid quarterly or annually
CONSUMER DENTAL CARE Available DC MD VA Only No claim forms No limitations or lifetime maximum
No deductibles No waiting periods for pre existing conditions
THE DENTAL INDEMNITY PLAN Available overseas and anywhere in the U S 1,000 maximum allowance per year

Annual deductible 50 per individual 150 per family No deductible for preventive care
Excellent benefits
Long Affordable quality telecommunications services through Rapid Link's CommLink Calling Card and for Distance those overseas Callback Service

Telephone Low flat rate pricing 24 hour Customer Service anytime Services No sign up fees No hidden costs
No monthly fees Convenient payment options

Senior Living AFSPA has a broad program for senior living alternatives At no additional cost to our members we offer Services information on senior living facilities throughout the U S

Legal Legal services are available through arrangements with four firms located in the Washington Metropolitan Services area Most areas of law are practiced Members of AFSPA are offered special rates
Travel AFSPA in conjunction with Worldwide Assistance Services Inc offers a valuable product called Travel Assistance Assistance International TAI TAI has local representatives in practically every country in the world and
Services can provide you with Unlimited emergency medical evacuation to the nearest medical facility where you can receive treatment
On the spot medical payments If you become injured or sick overseas payment can be made instantly to the medical provider Your only out of pocket expense is a standard 100.00 deductible
Worldwide medical referrals and medical monitoring Prescription replacement assistance
Repatriation of remains benefit
For more information on this service only please call 1 800 821 2828 and identify yourself as a member of AFSPA to receive special reduced member rates

For information and written material on any of the above programs please contact us at
American Foreign Service Protective Association 1716 N Street NW

Washington D C 20036 2902 202 833 4910 Email afspa afspa org
202 833 4918 fax Web site www afspa org

Benefits on this page are not part of the FEHB Contract

26 26
26 Page 27 28
Foreign Service Benefit Plan 2000
Section 6 How to File a Claim
Claim forms If you do not receive your identification card s within 60 days after the effective date of your identification cards enrollment you may call the Plan at 202 833 4910 to report the delay In the meantime use
and questions your copy of the SF 2809 enrollment form or your annuitant confirmation letter from OPM as proof of enrollment when you obtain services This is also the number to call for claim forms
or advice on filing claims
If you have a question concerning Plan benefits contact the Plan at 202 833 4910 or you may write the Plan at Foreign Service Benefit Plan 1716 N Street NW Washington DC 20036

You may also contact the Plan by fax at 202 833 4918 at its website at http www afspa org or by email at afspa afspa org

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

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

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

In addition
A copy of the explanation of benefits EOB from any primary payer must be sent with your claim See page 32 for Medicare claims

Bills for private duty nurses must show that the nurse is a registered or licensed practical nurse and include initial history and physical treatment plan indicating expected duration
and frequency from the attending physician and nursing notes from the provider of service
Claims for rental or purchase of durable medical equipment require the purchase price a prescription and a statement of medical necessity including diagnosis and estimated length

of time needed
Claims for physical speech and occupational therapy require an initial evaluation and treatment plan indicating length of time needed and progress therapy notes for each date of

service from the therapist
Claims for overseas foreign services
Enrollees serving overseas who are covered by both this Plan and the Medical and Health Program of the Department of State should submit claims to this Plan as described above

or as directed by the Office of Medical Services through your Administrative Office
Enrollees not covered by the Medical and Health Program of the Department of State should submit claims directly to this Plan as described above

Claims may include an English translation The Plan will translate claims and will convert to U S currency using the exchange rate applicable at the time the expense was incurred if
no translation or conversion is supplied by the member
For dental claims complete the front side of the Plan's standard claim form and attach a copy of the dentist's itemized bill The dentist's bill must include the name of the patient

dates of service itemized charges and the dentist's Federal Tax I D number The Plan does not have separate dental claim forms

For prescription drug claims see page 24
Cancelled checks cash register receipts or balance due statements are not acceptable

27 27
27 Page 28 29
Foreign Service Benefit Plan 2000
Section 6 How to File a Claim continued
After completing a claim form and attaching proper documentation send claims to
American Foreign Service Protective Association 1716 N Street NW

Washington D C 20036 2902
If you are overseas and have access to Department of State pouch mail you may send your claims in care of Department of State Washington D C 20520

Plan telephone number 202 833 4910
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 Plan will provide you with a record of expenses submitted and benefits paid for each claim that you file explanation of benefits It is your responsibility to keep these payment
records The Plan will not provide duplicate copies or year end summaries

Submit claims promptly Submit claims promptly as they are incurred Claims should be filed within 90 days after the expense for which the claim being made was incurred but in no event later than 2 years from
the date the expense in question was incurred We can extend this deadline if timely filing was prevented by administrative operations of Government or legal incapacity provided the claim
was submitted as soon as reasonably possible Once benefits have been paid there is a three year limitation on the reissuance of uncashed drafts

Direct payment to If you wish to authorize direct payment to a hospital complete an assignment form which will hospital or provider of be available at the hospital The hospital will bill the Plan but you must also complete and
care forward a claim form with the physician's statement

When more Reply promptly when the Plan requests information in connection with a claim If you do not information is needed respond the Plan may delay processing or limit the benefits available

28 28
28 Page 29 30
Foreign Service Benefit Plan 2000
Section 7 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless we determine it is medically necessary to prevent diagnose or treat your illness or condition The fact that one of our

covered providers has prescribed recommended or approved a service or supply does not make it medically necessary or eligible for coverage under this Plan

We do not cover the Services drugs or supplies that are not medically necessary following
Services not required according to accepted standards of medical dental or psychiatric practice in the United States

Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the

result of an act of rape or incest
Procedures services drugs and supplies related to impotency sex transformations sexual dysfunction or sexual inadequacy

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

Services and supplies furnished without charge while in active military service or required for illness or injury sustained on or after the effective date of enrollment 1 as a result of
an act of war within the United States its territories or possessions or 2 during combat
Services and supplies furnished by immediate relatives or household members such as spouse parents children brothers or sisters by blood marriage or adoption

Services and supplies furnished or billed by a noncovered facility except that medically necessary prescription drugs are covered
Services and supplies not recommended or approved by a covered provider
Services and supplies not specifically listed as covered
Services and supplies related to weight control or any treatment of obesity except surgery for morbid obesity

Non medical services such as recreational and educational therapy and nutritional counseling
Treatment of mental retardation and learning disabilities
Services for cosmetic purposes
Non surgical treatment of temporomandibular joint TMJ dysfunction including dental appliances study models splints and other devices

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

Charges the enrollee or Plan has no legal obligation to pay such as excess charges for an annuitant age 65 or older who is not covered by Medicare Parts A and or B see page 34
doctor charges exceeding the amount specified by the Department of Health and Human Services when benefits are payable under Medicare limiting charge see page 32 or State
premium taxes however applied and
Charges that the Plan determines to be in excess of the reasonable and customary charge

29 29
29 Page 30 31
Foreign Service 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 will determine who is responsible for paying for medical services and we will coordinate the payments
On occasion you may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled with us

If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a Medicare Choice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a Medicare Choice plan contact your retirement office If you later want to re enroll in the FEHB Program generally you may do so only at the next
Open Season
If you involuntarily lose coverage or move out of the Medicare Choice service area you may 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 benefits The following information applies only to enrollees and covered family members who are entitled
to benefits from both this Plan and Medicare You must disclose information about Medicare coverage including your enrollment in a Medicare Choice plan to this Plan this applies
whether or not you file a claim under Medicare You must also give this Plan authorization to obtain information about benefits or services denied or paid by Medicare when we request it It
is also important that you inform the Plan about other coverage you may have as this coverage may affect the primary secondary status of the Plan and Medicare see page 32

This Plan covers most of the same kinds of expenses as Medicare Part A hospital insurance and Part B medical insurance except that Medicare does not cover prescription drugs
The following rules apply to enrollees and their family members who are entitled to benefits from both an FEHB plan and Medicare

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

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 or
5 Services are received or charges are incurred at a VA Medical Center overseas or on board a ship not in a U S port or more than six hours before arrival at or after departure
from a U S port even if the ship is of U S registry In certain bordering areas of Canada and Mexico Medicare remains primary

For purposes of this section employed by the Federal Government means that you are a Federal employee and you do not hold an appointment described under Rule 6 of the following
Medicare is primary section

30 30
30 Page 31 32
Foreign Service Benefit Plan 2000
Section 8 Limitations Rules that affect your benefits continued
Medicare is primary if 1 You are an annuitant age 65 or over covered by Medicare Part A or Parts A and B and are not employed by the Federal Government

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

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

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

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

When Medicare is When Medicare is primary all or part of your Plan deductibles and coinsurance will be waived primary as follows
Inpatient Hospital Benefits If you are enrolled in Medicare Part A the inpatient hospital precertification requirement is waived and the Plan will waive the deductible and coinsurance
Surgical Benefits If you are enrolled in Medicare Part B the Plan will waive the coinsurance applicable to surgical care
Mental Conditions Substance Abuse Benefits If you are enrolled in Medicare Part A the inpatient hospital precertification requirement is waived and the deductible and coinsurance
will be waived If you are enrolled in Medicare Part B the outpatient deductible and coinsurance will be waived Visit limitations and the lifetime maximum still apply

Other Medical Benefits If you are enrolled in Medicare Part B the Plan will waive the deductible and coinsurance applicable to medical care and only prescription drugs obtained
from a doctor or other covered facility
Additional Benefits If you are enrolled in Medicare Part A the Plan will waive coinsurance applicable to skilled nursing care

Prescription Drugs If you are enrolled in Medicare Part B the Plan will waive the deductible applicable to prescription drugs If you are enrolled in Part B the Plan will not waive the 50
coinsurance applicable to prescription drugs purchased in a non participating pharmacy in the 50 United States the participating pharmacy copayment and the mail order copayment

Dental Benefits The coinsurance applicable to dental care is not 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

31 31
31 Page 32 33
Foreign Service Benefit Plan 2000
Section 8 Limitations Rules that affect your benefits continued
When you also enroll in a When you are enrolled in a Medicare Choice prepaid plan while you are a member of this Medicare Choice plan Plan you may continue to obtain benefits from this Plan If you submit claims for services

covered by this Plan that you receive from providers that are not in the Medicare plan's network the Plan will not waive any deductibles or coinsurance when paying these claims

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

not participate with Medicare accept assignment on certain claims If you use a doctor who accepts Medicare assignment for the claim the doctor is permitted to bill you after the Plan
has paid only when the Medicare and Plan payments combined do not total the Medicareapproved 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 Medicareapproved
amount Under this law if you use a doctor who does not accept assignment for the claim the doctor is permitted to bill you after the Plan has paid only if the Medicare and Plan
payments combined do not total the limiting charge Neither you nor your FEHB Plan is liable for any amount in excess of the Medicare limiting charge for charges of a doctor who does not
participate with Medicare The Medicare Summary Notice MSN form will have more information about this limit

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

How to claim benefits In most cases when services are covered by both Medicare and this Plan Medicare is the primary payer if you are an annuitant and this Plan is the primary payer if you are an employee
When Medicare is the primary payer your claims should first be submitted to Medicare The Plan has contracted with all 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 You may call the Plan at 202 833 4910 to find out if your
claims are being electronically filed If they are not you should initially submit your claims to Medicare After Medicare has paid its benefits the Plan will consider the balance of any covered
expenses To be sure your claims are processed by this Plan you must submit the MSN form from Medicare and duplicates of all bills along with a completed claim form The Plan
will not process your claim without knowing whether you have Medicare and if you do without receiving the MSN

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

to the National Association of Insurance Commissioners Guidelines
If we pay second we will determine how much of the charge we will pay for After the first plan pays we will pay the lesser of 1 our benefits in full or 2 a reduced amount that when

added to the benefits payable by the other coverage will not exceed 100 of covered expenses Thus the combined payments from both plans may not equal the entire amount billed
by the provider
Remember Even if you do not file a claim with your other plan you must still tell us that you have double coverage

32 32
32 Page 33 34
Foreign Service Benefit Plan 2000
Section 8 Limitations Rules that affect your benefits continued
When others are This subrogation and right of reimbursement provision applies when you or your dependent are responsible for injuries sick or injured as a result of the act or omission of another person or party The Plan has the

right to recover payments the Plan has made to you or your dependent from any recovery because of illness or injury caused by a third party In addition to its right of reimbursement
the Plan is subrogated to you or your dependent's present and future claims against a third party Third party means another person or organization

Liability insurance If you or your covered dependent suffer an injury or illness through the act or omission of and third party another you and your dependent agree 1 to reimburse the Plan for benefits paid by the Plan
actions in an amount not to exceed the amount of the recovery and 2 that the Plan is subrogated to your or your dependent's rights to the extent of the benefits paid including the right to bring
suit All recoveries whether by lawsuit settlement or otherwise and regardless of how characterized must be used to reimburse the Plan in full 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 or illness and 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 Failure to request or obtain any such assignment prior to
payment of benefits by the Plan when you or your dependent are sick or injured as a result of the act or omission of a third party will not in any way diminish the Plan's rights of
reimbursement and subrogation
When you or your dependent are sick or injured as a result of the act or omission of a third party the Plan shall have a lien on the proceeds of that claim in order to reimburse itself to the

full amount of benefits it has paid or may pay The Plan's lien shall apply to any and all recoveries for such claim regardless of the source whether by court order or out of court
settlement and shall be satisfied in full out of the proceeds of such recovery ies prior to the satisfaction of the claim of any individual including but not limited to the Plan enrollee
covered family member s and or that person's attorney
You are required to notify the Plan promptly of any claim that you may have for damages as a result of the act or omission of a third party 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 in full for the benefits paid or to be
paid by the Plan Any reduction of the Plan's lien for payment of attorney's fees or costs associated with the lien is subject to prior approval by the Plan

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 compensation We do not cover services that
You need because of a workplace related disease or injury that the Office of Workers Compensation Programs OWCP or a similar Federal or State agency determine they must provide

OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws

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

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

33 33
33 Page 34 35
Foreign Service Benefit Plan 2000
Section 8 Limitations Rules that affect your benefits continued
Overpayments The Plan will make reasonably diligent efforts to recover benefit payments made erroneously but in good faith and may apply subsequent benefits otherwise payable to offset any overpayments

Limit on your costs if The information in the following paragraphs applies to you when 1 you are NOT covered by you're age 65 or older either Medicare Part A hospital insurance or Part B medical insurance or both 2 you are
and don't have Medicare enrolled in this Plan as an annuitant or as a former spouse or family member covered by the family enrollment of an annuitant or former spouse and 3 you are not employed in a position
which confers FEHB coverage
Inpatient hospital If you are not covered by Medicare Part A are age 65 or older or become age 65 while receiving care inpatient hospital services and you receive care in a Medicare participating hospital the
law 5 U S C 8904 b requires the Plan to base its payment on an amount equivalent to the amount Medicare would have allowed if you had Medicare Part A This amount is called the
equivalent Medicare amount After the Plan pays the law prohibits the hospital from charging you for covered services after you have paid any deductibles coinsurance or copayments you
owe under the Plan Any coinsurance you owe will be based on the equivalent Medicare amount not the actual charge You and the Plan together are not legally obligated to pay the
hospital more than the equivalent Medicare amount
The Plan'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 services Claims for physician services provided for retired FEHB members age 65 and older who do not have Medicare Part B are also processed in accordance with 5 U S C 8904 b This law
mandates the use of Medicare Part B limits for covered physician services for those members who are not covered by Medicare Part B

The Plan is required to base its payment on the Medicare approved amount which is the Medicare fee schedule for the service or the actual charge whichever is lower If your doctor
is a member of the 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 coinsurance
If you go to a PPO doctor who does not participate with Medicare you are responsible for any deductible and the coinsurance Non participating physicians cannot bill you more than the

limiting charge 115 of the Medicare approved amount Unless the doctor's agreement with the Plan states otherwise the Plan will base its payment on the limiting charge

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
Other Medical Benefits the Plan will pay 80 of the Medicare approved amount You will only be responsible for any deductible and coinsurance equal to 20 of the Medicare approved
amount
If your physician does not participate with Medicare the Plan will still base its payment on the Medicare approved amount However in most cases you will be responsible for any deductible

or coinsurance and any balance up to the limiting charge amount 115 of the Medicareapproved 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 Plan'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 or write the Plan for assistance

34 34
34 Page 35 36
Foreign Service Benefit Plan 2000
Section 9 FFS facts
Precertification Precertify before hospital skilled nursing facility or hospice admission or receiving home health care

Precertification is not a guarantee of benefit payments Precertification of an inpatient admission is a predetermination that based on the information given the admission meets the
medical necessity requirements of the Plan It is your responsibility to ensure that precertification is obtained If precertification is not obtained and benefits are otherwise
payable benefits for the admission will be reduced by 500
The Plan also requires precertification for home health care hospice care and skilled nursing facility care In order to receive full Plan benefits you must precertify these services before

they are rendered Please refer to pages 22 and 23 for more information
To precertify a planned admission home health care hospice care or skilled nursing facility care

You your representative your doctor hospital home health agency hospice or skilled nursing facility must call Mutual of Omaha's Care Review Unit prior to the admission or
care The toll free number is 1 800 228 0286
Provide the following information enrollee's name and Plan identification number patient's name birth date and phone number reason for hospitalization or proposed treatment name

of hospital facility or home health agency name and phone number of admitting doctor and number of planned days of confinement or care

For hospital confinements when the above requirements are met the Care Review Unit will tell the doctor and hospital the number of approved days of confinement for the care of the
patient's condition
For home health care hospice care or skilled nursing facility care when the above requirements are met the Care Review Unit will notify the patient the doctor and the facility or

agency that the care is or is not certified as medically necessary
Written confirmation of the Plan's certification decision will be sent to you your doctor and the hospital If the length of stay or care needs to be extended follow the procedure below

Need additional days A review coordinator will contact your doctor before the certified length of stay ends to determine if you 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 Plan will not pay for charges incurred on any extra days that are determined
to be not medically necessary by the Plan during the claim review
You don't need to certify Medicare Part A or another group health insurance policy is the primary payer for the an admission when hospital confinement see page 31 Precertification is required however when Medicare
hospital benefits are exhausted prior to using lifetime reserve days
You are confined in a hospital outside the 50 United States

Maternity or When there is an unscheduled maternity admission or an emergency admission due to a condition emergency that puts the patient's life in danger or could cause serious damage to bodily function
admissions you your representative the doctor or the hospital must telephone 1 800 228 0286 within two business days following the day of admission even if the patient has been discharged from the
hospital Otherwise in patient benefits otherwise payable 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 day of the mother's discharge

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

35 35
35 Page 36 37
Foreign Service Benefit Plan 2000
Section 9 FFS facts continued
If you do not If precertification is not obtained before admission to the hospital or within two business days precertify following the day of a maternity or emergency admission or in the case of a newborn the

mother's discharge before home health care treatment or hospice or skilled nursing facility admission a medical necessity determination will be made at the time the claim is filed If the
Plan determines that the admission or care was not medically necessary the benefits will not be paid However medical supplies and services related to the inpatient admission otherwise payable
on an outpatient basis will be paid
If the claim review determines that the hospital 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 hospital admission precertified If the claim review determines that the home health care hospice care or skilled nursing facility admission was medically necessary
benefits will be reduced as stated on pages 22 and 23
If the admission or care is determined to be medically necessary but part of the length of stay or care was found to be not medically necessary benefits will not be paid for the portion of

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

Protection Against For those services with coinsurance the Plan pays 100 of reasonable and customary charges Catastrophic Costs for the remainder of the calendar year when out of pocket expenses for coinsurance and
deductibles in that calendar year exceed 2,500 for Self Only and 3,000 for Self and Family for you and any covered family members

Catastrophic Protection Out of pocket expenses for the purpose of this benefit are
The 175 per confinement deductible you pay for non PPO hospitals
The 10 you pay for other hospital charges if you live in the Plan's PPO Network Area and use a PPO hospital or if you live outside of the Plan's PPO Network Area

The 10 you pay for surgery if you live in the Plan's PPO Network Area and use a PPO provider or if you live outside of the Plan's PPO Network Area
The 15 you pay for other hospital charges if you live in the Plan's PPO Network Area and use a non PPO hospital
The 20 you pay for room and board charges if you live in the Plan's PPO Network Area and use a non PPO hospital
The 250 calendar year deductible under Other Medical Benefits
The 10 you pay for using PPO providers
The 20 you pay for using non PPO providers
The 20 you pay for purchasing prescriptions from pharmacies outside of the 50 United States or directly from doctors or other covered facilities

The following cannot be counted toward out of pocket expenses
Expenses in excess of reasonable and customary charges or maximum benefit limitations
Expenses for mental conditions substance abuse or dental care
Any amounts you pay because benefits have been reduced for non compliance with this Plan's cost containment requirements see pages 35 and 36

The 50 you pay for purchasing prescriptions at a non participating pharmacy in the 50 United States
Copayments you pay under the Prescription Drug Benefits and
Charges in excess of specific Plan allowances or for services that exceed the number allowed

Mental Conditions If your out of pocket expenses for treatment of covered mental conditions exceed 4,000 in a Benefit
calendar year for you and any covered family members the Plan will for the remainder of the calendar year pay 100 of reasonable and customary covered charges subject to benefit

maximums where provided see pages 18 and 19

36 36
36 Page 37 38
Foreign Service Benefit Plan 2000
Section 9 FFS facts continued
The following expenses are included under the Mental conditions catastrophic protection benefit
The 175 per confinement deductible you pay for non PPO hospitals
The 10 you pay for other hospital charges if you live in the Plan's PPO Network Area and use a PPO provider or if you live outside of the Plan's PPO Network Area

The 15 you pay for other hospital charges if you live in the Plan's PPO Network Area and use a non PPO provider
The 20 you pay for room and board charges if you live in the Plan's PPO Network Area and use a non PPO provider
The 10 you pay for PPO doctors in hospital visits subject to dollar and visit limitations
The 20 you pay for non PPO doctors inhospital visits subject to dollar and visit limitations
The 250 calendar year deductible
The 10 you pay for outpatient visits by a PPO doctor subject to visit limitations
The 25 you pay for outpatient visits by a non PPO doctor subject to visit limitations
The 25 you pay for day care subject to visit limitations
The 10 you pay for outpatient group therapy by a PPO doctor subject to dollar limitations and

The 50 you pay for outpatient group therapy by a non PPO doctor subject to dollar limitations

Expenses not included under the Mental conditions catastrophic protection benefit are
The amount you pay for failure to comply with the Plan's precertification requirement
Charges in excess of specific Plan allowances or for services that exceed the number allowed

Expenses in excess of reasonable and customary charges and
Expenses for treatment of substance abuse see page 19

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 ofpocket 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 An injury caused by an external force such as a blow or a fall and which requires immediate

medical attention Also included are animal bites poisonings and dental care required as a result of an accidental injury to sound natural teeth An injury to the teeth while eating is not
considered an accidental injury
Admission The period from entry admission into a hospital or other covered facility until discharge In counting days of inpatient care the date of entry and the date of discharge are counted as the
same day
Assignment An authorization by an enrollee or spouse for the Plan to issue payment of benefits directly to the provider The Plan 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

37 37
37 Page 38 39
Foreign Service Benefit Plan 2000
Section 9 FFS facts continued
Confinement An admission or series of admissions separated by less than 60 days to a hospital as an inpatient for any one illness or injury There is a new confinement when an admission is 1 for a cause

entirely unrelated to the cause for the previous admission 2 for an enrolled employee who returns to work for at least one day before the next admission or 3 for a dependent or
annuitant when confinements are separated by at least 60 days
Congenital anomaly A condition existing at or from birth that is a significant deviation from the common form or norm For purposes of this Plan congenital anomalies include protruding ear deformities cleft
lips cleft palates birthmarks webbed fingers or toes and other conditions that the Plan 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 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

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

Expense The cost incurred for a covered service or supply ordered or prescribed by a doctor An expense is incurred on the date the service or supply is received Expense does not include any
charge
1 for a service or supply that is not medically necessary or
2 that is in excess of the reasonable and customary charge for the service or supply

Group health coverage Health care coverage that a member is eligible for because of employment membership in or connection 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
38 38
38 Page 39 40
Foreign Service Benefit Plan 2000
Section 9 FFS facts continued
Home health care A plan of continued care and treatment of an insured person who is under the care of a doctor and whose doctor certifies that without home health care confinement in a hospital or skilled

nursing care facility would be required Home health care must be provided by a public agency or private organization that is licensed as a home health agency by the State and is certified as
such under Medicare
Hospice care program A coordinated program of home and inpatient pain control and supportive care for the terminally ill patient and the patient's family provided by a medically supervised team under
the direction of an independent hospice administration approved by the Plan

Medical emergency The sudden and unexpected onset of a condition or an injury that you believe endangers your life or could result in serious injury or disability and requires immediate medical or surgical
care that the covered person secures within 72 hours after the onset Medical emergencies include deep cuts broken bones heart attacks cardiovascular accidents poisonings loss of
consciousness or respiration convulsions and such other acute conditions as may be determined by the Plan to be medical emergencies

Medically necessary Services drugs supplies or equipment provided by a hospital or covered provider of the health care 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 substance abuse Diseases ICD as psychoses neurotic disorders or personality disorders other nonpsychotic
mental disorders listed in the ICD to be determined by the Plan 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 in which an individual 1 is the greater of 100 pounds or 100 over the standard weight as determined by the Plan with complicating medical condition s and 2 has been so
for at least five years despite documented unsuccessful attempts to reduce under a doctor monitored diet and exercise program

Prosthetic appliance A device which is surgically inserted or physically attached to the body to restore a bodily function or replace a physical portion of the body Prosthetic appliances include such items as
artificial legs artificial hips artificial knees intraocular lenses and pacemakers
Reasonable and Those charges that are comparable to charges made by other providers for similar services and customary supplies under comparable circumstances in the same geographic area The Plan's allowances
are developed from actual claims received in each Zip Code area throughout the United States as compiled by the Health Insurance Association of America and are updated twice a year at
the 90th percentile This method is used for determining reasonable and customary allowances for surgery maternity doctor and other professional services Other Medical and Mental
Conditions Substance Abuse Benefits and accidental injury care For other categories of benefits and for certain specific services within each of the above categories exceptions to this
general method for determining the Plan's allowances may exist
Sound natural tooth A tooth which is whole or properly restored and is without impairment periodontal or other conditions and is not in need of the treatment provided for any reason other than an accidental
injury

39 39
39 Page 40 41
Foreign Service Benefit Plan 2000
Section 10 FEHB facts
You have a right to the OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you following information 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 202 833 4910 or write the Foreign Service Benefit Plan 1716 N Street NW Washington DC 20036 You may also contact us by fax at
202 833 4918 by email at afspa afspa org or visit our website at www afspa org

Where do I get Your employing or retirement office can answer your questions and give you a Guide to information about Federal Employees Health Benefits Plans brochures for other plans and other materials you
enrolling in the FEHB need to make an informed decision about 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 benefits The benefits in this brochure are effective on January 1 If you are new to this Plan your and premiums effective coverage and premiums begin on the first day of your first pay period that starts on or after
January 1 Annuitants premiums begin January 1

What happens when I When you retire you can usually stay in the FEHB Program Generally you must have been retire enrolled in 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 coverage Self Only coverage is for you alone Self and Family coverage is for you your spouse and are available for me and your unmarried dependent children under age 22 including any foster or step children your
my family employing or retirement office authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years of age or older who became incapable of selfsupport
before 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 another FEHB plan

40 40
40 Page 41 42
Foreign Service Benefit Plan 2000
Section 10 FEHB facts continued
Are my medical and We will keep your medical and claims information confidential Only the following will have claims records access to it

confidential OPM this Plan and our subcontractors when they administer this contract
This Plan and appropriate third parties such as other insurance plans and the office of Worker 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

As part of its administration of the Prescription Drug Benefits the Plan may disclose information about a member's prescription drug utilization including the names of
prescribers to any treating prescribers or dispensing pharmacies or
OPM when reviewing a disputed claim or defending litigation about a claim

Information for new members Identification cards
We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF 2809 or the OPM annuitant confirmation letter until you receive 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 plan
Pre existing We will not refuse to cover the treatment of a condition that you or a family member had conditions before you enrolled in this Plan solely because you had the condition before you enrolled

When you lose benefits What happens if my You will receive an additional 31 days of coverage for no additional premium when
enrollment in this Plan Your enrollment ends unless you cancel your enrollment or 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 spouse coverage under your 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

41 41
41 Page 42 43
Foreign Service Benefit Plan 2000
Section 10 FEHB facts continued
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 32nd 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 and
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll in TCC If you leave Federal service your employing office will notify you of your right to enroll under TCC You must enroll within 60 days of leaving or receiving this notice whichever is later

Children You must notify your employing or retirement office within 60 days after your child is no longer an eligible family member That office will send you information about
enrolling in TCC You must enroll your child within 60 days after the child 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 that qualifies

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

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

You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law

If you leave Federal service your employing office will notify you if individual coverage is available You must apply in writing to us within 31 days after you receive this notice However

if you are a family member who is losing coverage the employing or retirement office will not notify you You must apply in writing to us within 31 days after you are no longer
eligible for coverage
Your benefits and rates will differ from those under the FEHB Program however you will not have to answer questions about your health and we will not impose a waiting period or limit

your coverage due to pre existing conditions
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Certificate of Group Coverage that indicates how long you have been enrolled with us You can use this certificate
Health Plan Coverage when getting health insurance or other health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting
periods limitations or exclusions 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

42 42
42 Page 43 44
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 202 833 4910 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

43 43
43 Page 44 45
Foreign Service Benefit Plan 2000
Index
This Index references both covered and non covered services and supplies
Accidental Injury 20 22 25 37 39 Explanation of Benefits 4 12 27 28 34 Orthotics 21
Acupuncture 20 Eyeglasses 20 21 Out of Pocket Expenses 4 5 9 18 32 36 37
Alcoholism and Substance Abuse Outpatient Services 15 22 37
Treatment 6 7 18 19 31 36 37 39 Fecal Occult Blood Test 21 Oxygen 20
Allogeneic Bone Marrow Transplant 16 Flexible Benefits Option 5
Ambulance 17 20 22 Fraud 43 Pap Smears 21
Anesthesia 4 15 17 Pathology 15 20
Artificial Eyes or Limbs 14 16 20 39 Gamete Intrafallopian Transfer GIFT 18 21 Pharmacies 4 6 20 21 23 24 31 36 41 43
Artificial Insemination 18 21 Group Therapy 4 18 19 Physical Therapy 20 22 27
Assignment 27 28 32 33 37 PreAdmission Testing 14
Assistant Surgeon 15 Hearing Aids 21 PPO 4 5 7 10 13 21 23 34 36 37
Assisted Reproductive Technology ART 18 21 Home and Office Visits 20 Precertification 5 6 13 17 19 22 23
Audits 41 Home Health Aide 22 31 35 37
Autologous Bone Marrow Transplant 16 Home Health Care 5 22 26 35 36 39 Prescription Drugs 4 19 20 21 23 25 29 31
Autologous Peripheral Stem Cell Support 16 Hospice Care 5 6 7 14 22 35 36 39 36 41
Hospital 4 10 13 20 22 25 28 30 Private Duty Nursing 13 14 21 22 27
Bassinet or Nursery Charges Inpatient 31 34 39 43 Professional Charges 14
Hospital 17 Prostate Cancer Screening PSA Test 21
Bilateral Multiple Incidental Surgical Identification Cards 9 23 27 41 Prosthetics 14 16 20 39
Procedures 15 Immunizations Childhood 18 20 22 Psychiatric Nurse 19
Birthing Centers 7 17 Impacted Teeth Removal of 16 25 Psychologist Clinical 8 19
Blood and Blood Plasma 20 Impotency 18 21 23 29 Radiation Therapy 20
Bone Marrow Transplant 16 In Vitro Fertilization 18 21 Reasonable and Customary R C 4 6 13 15
Breast Cancer Screening 20 Individual Therapy 19 37 17 25 36 37 39
Breast Prosthesis 16 20 Infertility 6 18 21 23 Registered Nurse RN 8 13 22 27
Inpatient Services 4 5 6 7 13 20 31 34 Renal Dialysis 22
Calendar Year Deductible 5 6 19 20 35 36 37 38 Rental of Durable Medical Equipment 20 27
21 24 31 36 Insulin 23 Retail Pharmacy Drug Card 4 23
Carryover 6 37 Intensive Care 13 Reversal of Voluntary Sterilization 18
Casts 20 Investigational or Experimental 10 29 40 Room and Board Hospital 5 6 9 13 17 36 37
Catastrophic Protection 3 9 18 36 37 Routine Physical Examination and
Cervical Cancer Screening 4 21 Jobst Stockings 21 Services 4 20 21
Chemotherapy 20
Chiropractor 21 Laboratory Tests 13 15 17 20 Second Surgical Opinion 16
Cholesterol Screening 21 Liability Insurance Third Party Actions 33 Semiprivate Accommodations 13 17
Circumcision 17 Licensed Medical Practitioners 8 Sexual Dysfunction or Sexual
Claiming Benefits 24 27 32 Licensed Practical Nurse LPN 13 22 27 Inadequacy 18 21 23 29
Clinical Social Worker 8 19 Lifetime Maximums 6 19 21 23 25 31 Skilled Nursing Facility SNF 5 8 14 23
Coinsurance 4 5 6 29 31 32 34 36 31 35 36
Colorectal Cancer Screening 4 21 Mail Order Prescription Drugs 4 23 24 31 Smoking Cessation Benefit 6 21 23
Congenital Anomaly 16 38 Mammograms 20 Speech Therapy 20 22 27
Confidentiality 41 Maternity Benefits 17 18 35 36 Splints 20 29
Contact Lenses 20 21 Medicaid 33 Sterilization Voluntary 18
Contraceptive Devices and Drugs 23 Medical Equipment 14 20 21 27 38 Subrogation Provision 33 41
Coordination of Benefits 30 32 41 Medically Necessary 14 15 17 21 29 35 36 39 Substance Abuse 6 7 14 18 19 31 36 37 39
Cosmetic Services 16 21 23 29 38 Medically Underserved Areas 8 21 Summary of Benefits 46 47
Covered Facilities 7 8 Medicare 4 6 7 8 13 24 27 29 32 34 35 39 Surgicenter 15 16
Covered Providers 8 Medicare Summary Notice 32 Syringes 23
Crutches 20 Mental Conditions 4 5 7 14 18 19 31 36 39
Custodial Care 7 14 26 38 Merck Medco Rx Services 24 25 Take home Items 14 16
Midwife 8 17 Temporary Continuation of Coverage TCC 40 42
Day Care 7 19 26 37 Morbid Obesity 29 39 Temporomandibular Joint TMJ
Deductible 4 5 6 9 13 17 19 20 Multiple Bilateral Incidental Dysfunction 25 29
21 23 24 28 29 31 32 34 36 37 41 Surgical Procedures 15 Tests and Laboratory Examinations 13 15 17
Dental 14 16 20 25 26 27 29 31 36 37 39 18 20 21
Diagnostic Services 18 20 21 Newborn Care 17 18 35 36 Tetanus diphtheria Booster 21
Disputed Claims 5 11 12 41 Non FEHB Benefits 26 Third Party Liability 33
Doctor Visits 4 14 16 17 18 20 22 Nurse Practitioner Clinical Specialist 8 19
Donor Expenses 15 16 Nursery 17 Vaccine Influenza and Pneumococcal 21
Drug Card 4 23 24 Nursing Facility Skilled 5 8 14 23 31 35 36 Visual Training 21

Obesity Morbid 29 39 Weight Control 29 39
Effective Date 6 27 29 37 38 Obstetrical Care 17 Well Child Care 18 20
Embyro Transfer 18 21 Ocular Injury 20 What is Not Covered 14 16 18 19 21
Emergency Admission 13 17 18 35 36 Occupational Therapy 20 22 27 23 25 29
Equipment Medical 14 20 21 27 38 39 Oral and Maxillofacial Surgery 16 25 Wheelchair 20
Exclusions 2 3 29 42 Organ Tissue Transplants 15 16 Workers Compensation 31 33 41
See also What is Not Covered Orthodontics 6 25
Experimental or Investigational 10 29 40 Orthoptics 21 X ray Services 20

44 44
44 Page 45 46
Notes
45 45
45 Page 46 47
Summary of Benefits for the Foreign Service 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 Code 401 Self Only Code 402 Self and Family
All items below with an asterisk are subject to the 250 calendar year deductible
Benefits Plan pays provides Page
Hospital PPO Benefit 100 of semiprivate room and board plus 90 of reasonable and customary

charges for other hospital services and supplies 13
Non PPO Benefit After the 175 inpatient hospital deductible per person per confinement the Plan pays 80 of semi private room and board charges plus 85 of

reasonable and customary charges for other hospital services and supplies 13
Outside PPO After the 175 inpatient hospital deductible per person per confinement the Network Area Plan pays 100 of semi private room and board charges plus 90 of

reasonable and customary charges for other hospital services and supplies 13 Surgical
Inpatient PPO Benefit and 90 of reasonable and customary charges 14 15 16 care
Out of Network Area Benefit

Non PPO Benefit 80 of reasonable and customary charges 14 15 16
Medical PPO Benefit 90 of reasonable and customary charges 20

Non PPO and 80 of reasonable and customary charges 20 Out of Network
Area Benefit
Maternity Same benefits as for illness and injury 17 18
Mental Conditions Same benefits as Hospital benefits referenced above 18
Substance Abuse 100 of charges up to 8,000 for one 28 day inpatient treatment program per calendar year detoxification 5 days confinement per calendar year 19

Hospital PPO Benefit 90 of reasonable and customary charges related to and rendered within
72 hours of surgery 90 of reasonable and customary charges for other outpatient services and supplies 15 16 17 18 20 21

Non PPO Benefit 80 of reasonable and customary charges related to and rendered within 72 hours of surgery 80 of reasonable and customary charges for other
outpatient services and supplies 15 16 17 18 20 21
Out of Network 90 of reasonable and customary charges related to and rendered within Area Benefit 72 hours of surgery 80 of reasonable and customary charges for other

outpatient services and supplies 15 16 17 18 20 21 Outpatient Surgical
care PPO Benefit and 90 of reasonable and customary charges 15 16
Out of Network Area Benefit

Non PPO Benefit 80 of reasonable and customary charges 15 16
Medical PPO Benefit 90 of reasonable and customary charges 20 21

Non PPO and 80 of reasonable and customary charges 20 21 Out of Network
Area Benefit
Maternity Same benefits as for illness and injury 17 18

46 46
46 Page 47 48
Summary of Benefits for the Foreign Service Benefit Plan 2000 continued
Benefits Plan pays provides Page

Home Health Care Precertified and non precertified benefits are payable Refer to Additional Benefits 22

Mental Conditions PPO Benefit 90 of reasonable and customary charges for individual therapy limited

Outpatient to 60 visits per person per year 90 of reasonable and customary care charges up to a maximum of 40 per session for group therapy 19
continued Non PPO and 75 of reasonable and customary charges for individual therapy limited Out of Network to 60 visits per person per year and for day care visits limited to 20 visits
Area benefit per person per year 50 of reasonable and customary charges up to 40 per session for group therapy 19

Substance Abuse Aftercare treatment program immediately following inpatient confinement is paid as part of the inpatient substance abuse benefit 19

100 of reasonable and customary charges for outpatient hospital and Emergency care physicians charges rendered within 72 hours after an accidental injury
accidental injury Other emergency services are covered the same as non emergency services 22

80 of reasonable and customary charges for drugs from a pharmacy outside of the 50 United States 50 of reasonable and customary
charges for drugs from a non participating pharmacy in the 50 United
Prescription drugs States 20 24 You pay 10 per generic prescription and 20 per brand name prescription

for up to a 30 day supply from a participating pharmacy you pay 15 per generic and 25 per brand name prescription for up to a 90 day supply of

medication ordered and supplied by mail 23 24 25
Routine preventive care and surgical procedures up to amounts shown
Dental care Orthodontics up to 1,000 per person per lifetime at 50 of reasonable and customary charges 25

Hospice care home health care private duty nursing at home childhood
Additional benefits immunizations renal dialysis skilled nursing facilities emergency ambulance service 22 23

Protection against catastrophic costs
Medical Surgical When out of pocket expenses exceed 2,500 in a calendar year for Self
Only and 3,000 for Self and Family the Plan pays 100 of reasonable
and customary covered charges for the remainder of that year subject to
benefit maximums 36
Mental Conditions When out of pocket expenses exceed 4,000 in a calendar year for you
and your family the Plan pays 100 of reasonable and customary covered
charges for the remainder of that year subject to benefit maximums 36 37

47 47
47 Page 48
Authorized for distribution by the
UNITED STATES OFFICE OF PERSONNEL MANAGEMENT

2000 Rate Information for Foreign Service Benefit Plan
FEHB benefits of this Plan are described in brochure RI 72 1
The 2000 rates for this Plan follow If you are in a special category refer to an FEHB Guide or contact the agency that maintains your health benefits enrollment

Premium
Biweekly Monthly

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

Self Only 401 78.83 32.56 170.80 70.55
Self and Family 402 175.97 94.91 381.27 205.64 48

Page Navigation Panel

1 2 3 4 5 6 7 8 9
10 11 12 13 14 15 16 17 18 19
20 21 22 23 24 25 26 27 28 29
30 31 32 33 34 35 36 37 38 39
40 41 42 43 44 45 46 47 48