Pages 1--44 from RI 72-005

Who may enroll in this Plan Only eligible active and retired rural letter carriers of the U S Postal Service are permitted to enroll in this Plan To enroll you must also be or must
become a member of the National Rural Letter Carriers Association

To become a member For information on how to become a member of the National Rural Letter Carriers Association contact your State Secretary's office or the National Rural
Letter Carriers Association

Membership dues Dues vary in each state
Enrollment code for this Plan 381 Self only
382 Self and family

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

Authorized for distribution by the
UNITED STATES OFFICE OF
PERSONNEL MANAGEMENT

RI 72 005 1
1 Page 2 3

Table of Contents
Page

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 9
Section 4 What if we deny your claim or request for preauthorization 10,11
Section 5 Benefits 11 24
Section 6 How to file a claim 25,26
Section 7 General exclusions Things we don't cover 27
Section 8 Limitations Rules that affect your benefits 28 32
Section 9 Fee for Service Facts 32 37
Section 10 FEHB facts 38 40
Inspector General Advisory Stop Healthcare Fraud 41
Summary of benefits Inside back cover
Premiums Back cover

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Introduction
Rural Carrier Benefit Plan 1630 Duke Street First Floor
Alexandria VA 22314 3466
This brochure describes the benefits you can receive from the Rural Carrier Benefit Plan under its contract CS 1073 with the Office of Personnel Management OPM to provide a health benefits plan Plan authorized by the Federal Employees Health Benefits
FEHB law This Plan is underwritten by the Mutual of Omaha Insurance Company which administers this Plan on behalf of the Carrier and is referred to as Carrier in this brochure

This brochure is the official statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this brochure If you are enrolled for Self and Family coverage each eligible family member is also entitled to these
benefits Nothing anyone says can modify or otherwise affect the benefits limitations and exclusions of this brochure
Because OPM negotiates benefits and premiums annually they change each year This brochure describes the only benefits available to you under this Plan in 2000 Benefit changes are effective January 1 2000 and are shown on page 4 You do not have a right to
benefits that are 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 Rural Carrier 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 Plan 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 to do if we deny your claim This section tells you what to do if you disagree with our decision not to pay for your claim
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

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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 to choose your own physicians
hospitals and other health care providers
The FFS plan reimburses you for 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 in certain locations in the following states Alabama Alaska Arkansas Washington DC Florida Georgia Idaho Illinois
Indiana Iowa Kentucky Louisiana Maryland Michigan Minnesota Mississippi Missouri North Carolina North Dakota Ohio Oklahoma Pennsylvania South Carolina Tennessee Texas Virginia
Washington West Virginia and Wisconsin This arrangement with health care providers gives you enhanced benefits or limits your out of pocket expenses

Section 2 How we change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copayment of 10 for all changes primary care office visits

This year you have a right to more information about this Plan care management and our networks
If you have a chronic or disabling condition or are in the second or third trimester of pregnancy and your provider is leaving our PPO network at our request without cause we will notify you You may

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

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

Changes to this Your share of the high option premium will increase by 17 for Self Only or 18 for Self and Plan Family
The Plan has added a Preferred Provider Organization PPO benefit PPO networks are available in certain locations in 28 States and Washington DC during 2000 Plan members who use
preferred providers will receive covered services at a reduced cost
The Plan has removed the annual limit 200 on routine physical examination charges under Other Medical Benefits

The Plan has increased the dollar limit from 200 to 300 under Additional Benefits for accidental injuries The time period for care for an accidental injury has increased from 72 hours to 5
days
The Plan has reduced the deductible for inpatient hospital stays for Mental Conditions Substance Abuse from 400 to 200 per person per calendar year We also have adjusted the hospital

benefit for inpatient stays from 100 for the first 31 days and 50 after 31 days to 100 for room and board and 80 for other hospital charges with no day limitation
The 250 limit for outpatient substance abuse care after an inpatient treatment program is removed We will consider aftercare charges as part of the amount allowed for substance abuse
treatment
The Plan has reduced from 100 to 85 the amount it will pay for professional fees for interpretation of x ray and laboratory tests done in conjunction with outpatient surgery

The Plan has reduced the ambulance service benefit from 100 of the first 50 and 75 of the remaining charges after the 250 calendar year deductible to 75 of the charges after the 250
calendar year deductible
The Plan has reduced the consultation benefit from 100 of the first 50 and 75 of remaining charges after the 250 calendar year deductible to 75 of reasonable and customary charges after

the 250 calendar year deductible
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Section 3 How to get benefits
How do I keep my health care expenses down

You can help FEHB plans are expected to manage their costs prudently All FEHB plans have cost containment measures in place All FFS plans include two specific provisions in their benefits
packages precertification of all inpatient admissions and flexible benefits option
As a result of your cooperative efforts the FEHB Program has been able to control premium costs Please keep up the good work and continue to help keep costs down

Precertification Precertification evaluates the medical necessity of proposed admissions and the number of days
required to treat your condition You are responsible for ensuring that the precertification requirement is met You or your doctor must check with Mutual of Omaha's Care Review Unit

before being admitted to the hospital Be a responsible consumer Be aware of your Plan's cost containment provisions Avoid penalties and help keep premiums under control by following the
procedures specified on pages 33 and 34 of this brochure
Flexible benefits option Under the flexible benefits option the Carrier has the authority to determine the most effective
way to provide services The Carrier may identify medically appropriate alternatives to traditional care and coordinate the provision of Plan benefits as a less costly alternative benefit

Alternative benefits are subject to ongoing review The Carrier may decide to resume regular contract benefits at its sole discretion Approval of an alternative benefit is not a guarantee of
any future alternative benefits The decision to offer an alternative benefit is solely the Carrier's and may be withdrawn at any time It is not subject to OPM review under the disputed claims
process
Preferred Provider This Plan offers its members who live in a Preferred Provider network area the opportunity to Organization reduce out of pocket expenses by choosing providers who participate in the Plan's Preferred
Provider Organization PPO Consider the PPO cost savings when you review Plan benefits and if you live in a PPO network area check with the Carrier to find out which local facilities
and providers are part of the network Check with your doctor to see whether he or she has admitting privileges at a PPO hospital Provider networks may be more extensive in some areas
than others The availability of every specialty in all areas cannot be guaranteed If no PPO provider is available or you choose not to use a PPO provider in your area the normal nonPPO
benefits apply
In addition to a preferred provider network your Plan has discount arrangements with other hospitals physicians and other medical facilities throughout the country with United Payers

United Providers formerly America's Health Plan Their terms vary but the purpose is the same to reduce your out of pocket expenses on covered services

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

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

Calendar year The calendar year deductible is the amount of covered expenses an individual must incur for covered services and supplies each calendar year before the Plan pays certain benefits The
deductible is the 250 you pay before the Plan starts paying expenses for Other Medical Benefits

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Section 3 How to get benefits continued
Hospital You pay 200 per person for the first non PPO hospital admission in a calendar year before the Plan starts paying inpatient room and board benefits

Dental You pay a 50 deductible per person each calendar year for all dental procedures included in the Class B Schedule of Dental Allowances You may count toward the deductible only those
expenses covered under the Class B Schedule of Dental Allowances You cannot count toward the deductible any charges in excess of the amounts listed in the Class B Schedule of Dental
Allowances

Mental conditions For inpatient treatment of mental conditions you pay the first 200 of covered hospital charges per person each calendar year in a non PPO hospital or facility

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 per person Under a family enrollment the deductible is considered satisfied and benefits are payable for all family members 1 after two
family members have each met their calendar year deductible or 2 when the combined covered expenses applied to the deductibles for all family members reach 500 during a
calendar year

Coinsurance Coinsurance is the stated percentage of covered charges you must pay after you have met any applicable deductible The Plan will base this percentage on either the billed charge or the
reasonable and customary charge whichever is less For instance when a 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 may be responsible for any excess charge over the Plan's reasonable and customary allowance For example if the
provider ordinarily charges 100 for a service but the Plan's reasonable and customary allowance is 95 the Plan will pay 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 Your total responsibility is 24

If provider waives If a provider routinely waives does not require you to pay your share of the charge for your 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 When inpatient claims are paid according to a Diagnostic Related Group DRG limit for charges are instance for admissions of certain retirees who do not have Medicare see page 31 the Plan
limited by law 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 Inpatient benefits for the treatment of alcoholism and drug abuse are limited to two maximums inpatient programs per person per lifetime
The smoking cessation benefit is limited to one program per person per lifetime
Diagnosis and treatment of infertility is limited to 5,000 per person per lifetime

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Section 3 How to get benefits continued
Do I have to You usually do not have to submit claims to us if you use preferred providers If you file a claim submit claims please send us all of the documents for your claim as soon as possible You must submit claims
within two years after the date you received the service or supply Either OPM or we can extend this deadline if you show that circumstances beyond your control prevented you from filing on time

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

Who provides my health In a Fee for Service Plan you may choose any covered facility or provider care

Facilities and Other Providers 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 post partum care

Hospice A public or private agency or organization that
1 Administers and provides hospice care and
2 Meets one of the following requirements
a is licensed or certified as such by the State in which it is located
b is certified or is qualified and could be certified to participate as such under Medicare
c is accredited as such by the Joint Commission on the Accreditation of Healthcare Organizations JCAHO or

d meets the standards established by the National Hospice Organization
Hospital 1 An institution which is accredited as a hospital under the hospital accreditation program of the JCAHO or 2 any other institution that is operated pursuant to law under the supervision
of a staff of doctors and with twenty four hour a day nursing service 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 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
For inpatient treatment of alcohol and drug abuse the term hospital also includes a freestanding alcohol and drug abuse treatment facility approved by the JCAHO

Skilled nursing An institution or that part of an institution that provides convalescent skilled nursing care 24 facility hours a day and is certified or is qualified and could be certified as a skilled nursing facility
under Medicare
Covered providers A licensed doctor of medicine M D a licensed doctor of podiatry D P M or licensed doctor of osteopathy D O Other covered providers include a qualified clinical psychologist clinical
social worker physician assistant optometrist dentist chiropractor nurse midwife nurse practitioner clinical specialist and nursing school administered clinic For purpose 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

A qualified clinical psychologist includes 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 the service is performed This presumes a licensed individual has demonstrated to the satisfaction of state licensing officials that he she is qualifed to provide psychological services
in that state by virtue of academic and clinical experience

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Section 3 How to get benefits continued
Coverage in Within States designated as medically underserved areas any licensed medical practitioner will be medically underserved treated as a covered provider for any covered services performed within the scope of that license
areas 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 Benefits under this Plan are available from facilities such as hospitals and from providers such as arrangements doctors and other health care professionals who provide covered services This Plan covers two
types of facilities and providers 1 those who participate in a preferred provider organization PPO and 2 those who do not Who these health care providers are and how benefits are paid
for their services are explained below In general it works like this
PPO facilities and providers have agreed to provide services to Plan members at a lower cost than you would usually pay a non PPO provider Although a PPO is not available in all locations or for

all services when you use these providers you help to contain health care costs and reduce what you pay in out of pocket costs The selection of PPO providers is solely the Carrier's responsibility
and continued participation of any specific provider in the PPO cannot be guaranteed
While PPO providers agree with the Carrier to provide services the final decision about health care is the responsibility of the doctor and the patient Benefit decisions made by the Carrier are

dependent on the terms of the insurance contract PPO benefits apply only when you use a participating PPO provider If no PPO provider is available or you choose not to use a PPO
provider when one is available the normal non PPO Plan benefits apply
When you use a PPO hospital please keep in mind that the health care professionals who provide services to you in the hospital such as radiologists anesthesiologists and pathologists may not all

participate in the PPO If they do not participate in the PPO they will be paid as non PPO providers by the Plan

The Plan pays its normal benefits to non PPO facilities and providers for services and you are responsible for any balance due

This Plan's PPO Plan members who live in certain parts of the country may use a Preferred Provider Organization PPO network of hospitals health care facilities doctors and other health care professionals PPO
networks are located in certain areas of the following states Alabama Alaska Arkansas Florida Georgia Idaho Illinois Indiana Iowa Kentucky Louisiana Maryland Michigan Minnesota
Mississippi Missouri North Carolina North Dakota Ohio Oklahoma Pennsylvania South Carolina Tennessee Texas Virginia Washington West Virginia Wisconsin and Washington DC
These PPO providers agree to render services to Plan members and their dependents for a negotiated fee You can choose a PPO provider or a non PPO provider at the time care is needed

If a Plan member uses a PPO hospital the 200 deductible and the 20 coinsurance are waived for medical surgical and maternity stays If the hospital stay is for mental health care in a PPO
hospital or facility the 200 deductible and the 20 coinsurance are waived When a PPO doctor performs surgery the Plan pays 90 of the surgeon's negotiated fee For PPO doctor office visits
the Plan pays 100 of the negotiated fee after you pay a 15 copayment per visit For other services provided the PPO pays doctors and other health care professionals under Other Medical
Benefits at 85 of the negotiated fee after a 250 deductible per person each calendar year
When you are admitted to a PPO hospital show your Rural Carrier Benefit Plan RCBP identification card to the Admissions Department Please advise the admissions staff that the RCBP

participates in the PPO program and complete an assignment of benefits to the hospital The hospital will file the claim for you and the benefits will be paid to the hospital Plan members who
live in a PPO area will receive a listing of the participating hospitals and health care facilities in the service area

Follow the same procedure when you receive services from a PPO doctor Doctors and other health care professionals are generally located in the same location as PPO hospitals For information
on the specialists general practitioners and hospitals in your area please call 1 800 638 8432 or refer to the Carrier's Web site at http www mutualofomaha com service provider index html
The Carrier is solely responsible for selecting PPO providers and any questions about PPO providers should be directed to Mutual of Omaha at 1 800 638 8432

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Section 3 How to get benefits continued
What do I do if I'm in First call Mutual of Omaha's Customer Service Department at 1 800 638 8432 If you are new the hospital when I join to the FEHB Program we will reimburse your covered expenses If you are currently in the
this Plan FEHB Program and are switching to us your former plan will pay for the hospital stay until You are discharged not merely moved to an alternate care center or

You exhaust the benefits available from your former plan or
The 92nd day after you become 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 able illness and my provider 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 the Plan leaves the second or third trimester of pregnancy you may continue to see your OB GYN until the end of
Program 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 of pregnancy Your new plan will pay for your care for up to 90 days after you receive notice that your prior plan is
leaving the FEHB Program If you are in the 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 A drug device or biological product is experimental or investigational if the drug device or if a service is biological product cannot be lawfully marketed without approval of the U S Food and Drug
experimental or Administration FDA and approval for marketing has not been given at the time it is furnished investigational to you 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 on going 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

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Section 4 What to do if we deny your claim or request for preauthorization
What should I do Before you ask us to reconsider your claim you should first check with your provider or facility before filing a to be sure that the claim was filed correctly For instance did the provider use the correct
disputed claim procedure code for the services performed surgery laboratory test X ray office visit etc Have your provider indicate any complications of any surgical procedure performed
Your provider should also include copies of an operative or procedure report or other documentation that supports your claim

If we deny your request for pre authorization or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial We may extend this time limit if you can 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 pre authorization or
3 Ask for more information

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

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

When may I ask OPM You may ask OPM to review a denial after you ask us to reconsider our initial denial OPM will to review a denial determine if we correctly applied the terms of our contract when we denied your claim
What if I have a serious Call us at 1 800 638 8432 and we will expedite our review or life threatening condition
and you haven't responded to my request
for pre authorization
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 care and inform OPM so that they can give your claim expedited treatment too Alternatively you can

my condition is serious call OPM's Health Benefits Contract Division II at 1 202 606 3818 between 8 a m and 5 p m or life threatening Serious or life threatening conditions are ones that may cause permanent loss of bodily functions
or death if they are not treated as soon as possible
Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold time 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 additional information we asked for and we did not answer within 30 days In this case OPM must receive your request within 120 days of the date we asked
you for additional information

What do I send to Your request must be complete or OPM will return it to you You must send the following OPM information
1 A statement about why you believe our decision is wrong based on specific benefit provisions in this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim 4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to which claim

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Section 4 What to do if we deny your claim or request for preauthorization continued
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 Programs disputed claim to OPM Contracts Division II P O Box 436 Washington DC 20044

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

What laws apply if I file Federal law governs your lawsuit benefits and payment of benefits The Federal court will base a lawsuit 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 you Privacy Act 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 claim 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

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 33 and 34 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 29

Room and board For each confinement the Plan will consider semiprivate or ward accommodations in a hospital to include all nursing care meals and special diets The Plan will consider charges for
accommodations in intensive care units for each confinement even though these charges may exceed the hospital's semiprivate room rate

If a private room is used the Plan will consider the average semiprivate room rate charged by the hospital or if the hospital has only private rooms the average semiprivate rate for hospitals in the
same geographic area However if the patient's isolation is medically necessary to prevent contagion to others the private room charge will be considered

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Section 5 Benefits continued
PPO benefit The Plan pays room and board at 100 with no deductible when admission is to a PPO hospital
See page 8

Non PPO benefit After you pay a 200 deductible for the first admission in a calendar year the Plan pays 100 of
the semiprivate room and board charges

Other charges Other charges include but are not limited to
Use of operating room
Surgical dressings
Drugs and medicines for use in the hospital
X ray and laboratory examinations
Blood or blood plasma if not donated or replaced and its administration

PPO benefit The Plan pays other hospital charges at 100 when admission is to a PPO hospital See page 8
Non PPO benefit The Plan pays other hospital charges at 80

Limited benefits Pre admission The Plan pays 100 of reasonable and customary charges for pre admission testing received
testing within 7 days of admission as an inpatient to a hospital
Hospitalization for The Plan pays Inpatient Hospital Benefits in connection with dental procedures only when a dental work nondental physical impairment exists which makes hospitalization necessary to safeguard the
health of the patient
Related benefits Consultations Inpatient consultations are covered under Other Medical Benefits see page 18

Professional Charges for professional services of a doctor even though billed by a hospital as part of the charges hospital services are covered under Other Medical Benefits see page 18
Prosthetic Prosthetic appliances e g pacemakers artificial hips intraocular lenses provided by a hospital appliances are covered under Other Medical Benefits see page 18
Take home items Drugs and medicines and other medical supplies furnished upon discharge for use at home are covered only under Other Medical Benefits see page 18 or Prescription Drug Benefits see page
22

What is not A hospital admission that is not medically necessary i e the medical services did not covered require the acute hospital inpatient overnight setting but could have been provided in a
physician's office the outpatient department of a hospital or some other setting without adversely affecting the patient's condition or the quality of medical care rendered

Confinement in nursing homes rest homes places for the aged convalescent homes or any place that is not a hospital skilled nursing facility or hospice see definitions
Custodial care see definition even when provided by a hospital
Inpatient private duty nursing
Personal comfort items such as radio television telephone air conditioner beauty and barber services guest cots guest meals newspapers and similar items

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Section 5 Benefits continued
Surgical Benefits
What is covered The Plan pays for the following services

Hospital Charges for normal pre and post operative care by the doctor who performs surgery including inpatient and inhospital visits for the first 14 days after an operation are considered to be part of the surgical
outpatient fee Hospital visits by the surgeon after 14 days are considered under Other Medical Benefits see page 18 Charges for use of an outpatient surgical facility are covered as Additional Benefits see
page 21
PPO benefit If a PPO doctor performs the surgery the Plan will pay 90 of the surgeon's negotiated fee for
the inpatient or outpatient surgical procedure see page 8

Non PPO benefit The Plan pays 85 of the reasonable and customary charges for inpatient or outpatient surgery by
a non PPO doctor

Multiple surgical When multiple or bilateral surgical procedures that add time or complexity to patient care are procedures performed during the same operative session by a doctor surgeon or podiatrist the Plan pays as
follows the value of the major procedure plus 50 of the value of the lesser procedure s will be considered

Incidental When an incidental procedure e g incidental appendectomy lysis of adhesions excision of scar procedures
is performed through the same incision the reasonable and customary allowance will be that of the major procedure only Separate benefits will not be provided for procedures deemed by the Plan to

be incidental to the total surgery

Assistant surgeon The Plan pays 85 of reasonable and customary charges of an assistant surgeon for inpatient or inpatient outpatient outpatient surgery when determined by the Plan to be medically necessary

Second opinion The Plan pays 100 of reasonable and customary charges for a second outpatient surgical voluntary opinion by an independent consulting doctor other than the surgeon
Anesthesia The Plan pays 85 of the reasonable and customary charges for general anesthesia and its
administration

Organ tissue All reasonable and customary charges incurred for a covered surgical transplant whether incurred transplants and by the recipient or donor will be considered expenses of the recipient and will be covered the
donor expenses same as for any other illness or injury
What is covered Cornea heart kidney liver pancreas when condition is not treatable by use of insulin
therapy heart lung single lung and double lung transplants

Bone marrow transplants 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 acute lymphocytic or non lymphocytic leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma advanced neuroblastoma
testicular mediastinal retroperitoneal and ovarian germ cell tumors epithelial ovarian cancer breast cancer and multiple myeloma

Related medical and hospital expenses of the donor when the recipient is covered by the Plan Recipient means an insured person who undergoes an operation to receive an organ
transplant Donor means a person who undergoes an operation for the purpose of donating an organ for transplant surgery

What is not covered Transplants not listed as covered

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Section 5 Benefits continued
Cosmetic surgery Cosmetic surgery see definition is covered only if necessary for repair of accidental injury sustained while covered by the FEHB Program to correct congenital anomalies or for
reconstruction of a breast that was removed or partially removed

Oral and Oral surgery is covered only for maxillofacial
The extraction of impacted unerupted teeth surgery
Correction of fractures of the jaw and or facial bones
Removal of salivary stones
Correction of cleft palate
Correction of severe malocclusion protruding or retruding mandible or maxilla caused by disease injury or congenital malformation

Excision of bony cysts of the jaw unrelated to tooth structures
Excision of pathological tori tumors and premalignant and malignant lesions
Surgical correction of temporomandibular joint TMJ dysfunction
Dental surgical biopsy
Frenectomy or frenotomy unrelated to orthodontic care

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 the treatment of any physical complications including lymphedemas and for breast prostheses including surgical bras and
replacements see page 18

What is not covered Treatment or removal of corns and calluses or trimming of toenails
Radial keratotomy or similar surgery done in treating myopia except for cornea graft
Dental appliances study models splints and other devices or services related to the treatment of TMJ dysfunction

Reversal of voluntary surgical sterilization

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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 33 and 34 for details

Room and board
PPO benefit The Plan pays room and board at 100 with no deductible when admission is to a PPO hospital
See page 8

Non PPO benefit After you pay a 200 deductible for the first admission in a calendar year the Plan pays 100 of
the semiprivate room and board charges

Other charges 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 Doctor's in hospital charges for routine newborn care and any other charges which are expenses of the child will be considered only if the

child is covered by a family enrollment Routine circumcision is covered under Surgical Benefits for family enrollments

PPO benefit The Plan pays other hospital charges at 100 when admission is to a PPO hospital See page 8
Non PPO benefit The Plan pays 80 of other hospital charges

Outpatient care The Plan pays 100 of the reasonable and customary charges for covered services at the time of delivery when

Delivery is on an outpatient basis or
Delivery is at a licensed birthing center or
Inpatient delivery results in a hospital confinement of one day overnight or less

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 at 100 of reasonable and customary

charges
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 only the regular Plan benefits will apply

Obstetrical care Prenatal and postpartum doctor and midwife visits are covered under Other Medical Benefits page 18
PPO benefit If a PPO provider performs the delivery the Plan will pay 90 of the negotiated fee See page 8
Non PPO benefit The Plan will pay 85 of the reasonable and customary charges for delivery by a doctor or
midwife

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Section 5 Benefits continued
Maternity Benefits Related benefits

Diagnosis and Services for the diagnosis and treatment of infertility are covered under Other Medical Benefits treatment of see page 19
infertility
Tests Sonograms amniocentesis and other related tests on the unborn are covered under Other Medical Benefits see page 18

Voluntary The Plan pays the same benefits as for any other surgical procedure See Surgical Benefits page sterilization 13

For whom Benefits are payable under Self Only enrollments and for family members under Self and Family enrollments
What is not covered 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
Services and supplies related to treatment of impotency
Reversal of voluntary surgical sterilization
Assisted Reproductive Technology ART procedures such as artificial insemination in vitro fertilization embryo transfer or placement and GIFT Services and supplies related to

ART procedures are not covered

Mental Conditions Substance Abuse Benefits What is covered The Plan pays for the following services
Mental conditions
Inpatient care The Plan pays for inpatient care as shown below

Precertification The medical necessity of your admission to a hospital or other covered facility must be
precertified for you to receive full Plan benefits Emergency admissions must be reported within two business days following the day of admission even if you have been discharged Otherwise

the benefits payable will be reduced by 500 See pages 33 and 34 for details
PPO benefit The Plan pays 100 of the room and board charges and other hospital charges with no
deductible when admission is to a PPO hospital or facility See page 8

Non PPO benefit After a 200 deductible per person per calendar year the Plan pays 100 of the room and board
charges and 80 of other charges

Partial If you or a covered family member incurs expense for partial hospitalization the Plan will pay
hospitalization for each day of confinement as follows

Benefits payable are subject to the same limitations and conditions including precertification as for inpatient care and

At least four hours of continuous treatment but not more than 12 hours in any consecutive 24 hour period in a hospital

Partial hospitalization must be a medically necessary alternative to inpatient hospitalization

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Section 5 Benefits continued
Catastrophic When the 20 you pay for covered hospital charges and the deductible non PPO totals 8,000
protection in a calendar year for one member the Plan will then pay 100 of that person's covered hospital
benefit charges for the rest of that calendar year

Inpatient The Plan will consider charges for psychiatric treatment sessions including group sessions up to
outpatient a maximum benefit of 75 per session even when billed by a hospital or provided by the hospital
visits staff These services are covered only when rendered by a covered provider see pages 7 and 8
even when billed for by a hospital or provided by hospital personnel These services are not subject to a deductible or coinsurance and their cost does not apply to the catastrophic protection

benefit for mental conditions Charges for psychological testing and pharmacological visits are covered under Other Medical Benefits see page 18 The medical management of mental
conditions will be covered under Other Medical Benefits see page 18 Related drug costs will be covered under the Plan's Prescription Drug Benefits see page 22

Substance abuse
Precertification The medical necessity of your admission to a hospital or other covered facility must be
precertified for you to receive full Plan benefits Emergency admissions must be reported within two business days following the day of admission even if you have been discharged Otherwise

the benefits payable will be reduced by 500 See pages 33 and 34 for details
PPO benefit The Plan will pay up to 6,000 for inpatient care in a PPO facility or outpatient care by a PPO
provider See page 8

Non PPO benefit The Plan will pay up to 5,500 for an inpatient treatment program in an accredited facility or an
outpatient treatment program

Lifetime maximum The Substance Abuse Benefit is limited to two inpatient programs per person per lifetime No
other benefits are payable for this condition

What is not covered All charges for chemical aversion therapy conditioned reflex treatments narcotherapy or any similar aversion treatments and all related charges including room and board

Biofeedback and milieu therapy
Counseling or therapy for educational or behavioral problems or related to mental retardation or learning disabilities

Marital family or other counseling services

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Section 5 Benefits continued
Other Medical Benefits What is covered

Physician visits
PPO benefit The Plan pays in full after a 15 copayment for each covered outpatient visit The 250 deductible
does not apply to this benefit and the copayment does not count toward the out of pocket limit The copayment applies to each visit and only one copayment will be applied per day per person

Coverage is provided for the following services performed in a physician's office
Office visits including consultations
Ophthalmology exam
Physical therapy
Surgery follow up
Injections including allergy injections
Allergy testing
Radiation therapy and
X ray and laboratory services in the physician's office

The 15 copayment and 100 benefit does not apply to office surgery prescription drugs and any supplies provided by the physician and services not received in the physician's office

Non PPO benefit After the 250 calendar year deductible the Plan pays 75 of reasonable and customary charges
Other Services PPO benefit After the 250 calendar year deductible the Plan pays 85 of the PPO provider's negotiated fee

See page 8
Non PPO benefit After the 250 calendar year deductible the Plan pays 75 of the reasonable and customary
charges

Covered services Coverage is provided for the following other services when prescribed by a physician and supplies
Hospital visits and inpatient consultations
Prenatal and postpartum physician and midwife visits
Insulin including syringes
Physical therapy performed by a registered physical therapist
Oxygen and equipment for its use
Electroshock therapy
Radiation therapy
Chemotherapy
Allergy treatment including injections and testing
Purchase of one pair of eyeglasses or contact lenses required after intraocular surgery within one 1 year of the surgery Spare glasses or lenses are not covered after surgery

Hospital outpatient services and supplies
Speech therapy by a qualified speech therapist when loss of speech is due to illness or injury
Rabies shots when the individual has been exposed to active rabies
X ray and laboratory examinations except for dental work
Pathological services and machine diagnostic tests
Orthopedic appliances including orthopedic braces and crutches
Prosthetic appliances such as artificial limbs joints and eyes including replacement repair or adjustment when required because of a change in the patient's physical condition

Breast prostheses including the surgical bra used for an external prosthesis following a mastectomy In addition to the initial prostheses following mastectomy we will provide
necessary replacement prostheses and bras
Professional ambulance service to the nearest hospital or medical facility equipped to handle the patient's condition for accidents acute illnesses or for covered inpatient care

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Section 5 Benefits continued
Preventive services
PPO benefit The Plan pays in full after a 15 copayment for the physician's professional fee and services
provided in the physician's office For all other services and supplies provided on an outpatient basis the Plan pays 85 of the covered charge after the 250 calendar year deductible

Non PPO benefit After the 250 calendar year deductible the Plan pays 75 of the reasonable and customary charges
The Plan pays for the following preventive services
Physical exam We pay for one routine physical exam per person per calendar year A routine physical exam is a
complete evaluation of a patient without symptoms or illness and includes a comprehensive history and physical examination

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
From age 65 and over one mammogram screening every two consecutive calendar years

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 For members age
screening 50 or older coverage of a screening sigmoidoscopy every five years

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

Limited benefits
PPO benefit After the 250 calendar year deductible the Plan pays 85 of the PPO provider's negotiated fee
See page 8

Non PPO benefit After the 250 calendar year deductible the Plan pays 75 of the reasonable and customary charges

Chiropractor Plan pays up to 300 per person each calendar year for service of a chiropractor Services of a chiropractor are not covered under any other Plan benefit except as described on page 8
Chiropractic charges applied to satisfy the deductible are counted toward the benefit limit
Diagnosis and The Plan will pay up to 5,000 per person per lifetime for the following services and supplies treatment of
Initial diagnostic tests and procedures done solely to identify the cause of the inability to infertility conceive

Fertility drugs hormone therapy and related services
Medical or surgical services performed solely to create or enhance the ability to conceive

Durable medical The Plan pays for rental up to the purchase price of durable medical equipment see definition equipment Purchase of equipment is at the Plan's option and must also be preapproved To obtain
preapproval request Plan approval in writing within 31 days of the initial rental and include your doctor's statement of medical necessity Unless you request an extended rental within 31 days the
Plan will not pay for more than three rental months even if it eventually authorizes purchase of the equipment

Occupational Plan pays for up to 30 days of occupational therapy each calendar year when therapy is under the therapy supervision of a doctor
Smoking cessation The Plan will pay up to 100 per member per lifetime for enrollment in one smoking cessation benefit program including any related prescription drugs Charges applied to satisfy the deductible are
counted toward the benefit limit Smoking cessation drugs and medications are not available under any other Plan provisions

Well child care The Plan will pay charges for all routine office visits and testing for children up to age 24 months
See Additional Benefits for the benefit for routine childhood immunizations

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Section 5 Benefits continued
What is not covered Orthopedic shoes orthotics and other devices to support the feet
Corsets and trusses
Provocative food testing end point titration techniques and sublingual allergy desensitization

Sun or heat lamps whirlpool baths heating pads air purifiers humidifiers exercise devices and other items that do not meet the definition of durable medical equipment
Eye exercises and visual training orthoptics
Custodial care see definition
Telephone consultations
Jobst stockings unless determined to be medically necessary

Additional Benefits
Accidental injury If you or a family member is accidentally injured the plan will pay 100 of reasonable and customary charges up to the maximum benefit for

Surgery and medical care by a physician
Hospital room and board and other related services and supplies
Private duty nursing services in your home by a registered graduate nurse R N
X ray and laboratory tests
Drugs and medicines
Casts splints braces and crutches
Surgical dressings

To be eligible for benefits under this provision initial and follow up care must be received within 5 days of the injury or medical emergency

Maximum benefit
PPO benefit The Plan will pay up to 500 if you receive care from a PPO provider See page 8

Non PPO benefit The Plan will pay up to 300 if you receive care from a Non PPO provider
Charges exceeding the maximum benefit will be considered under Other Medical Benefits

Cancer treatment The Plan will pay without dollar limitation 100 of the reasonable and customary charges for any services and supplies normally covered by the Plan for the treatment of any illness diagnosed
as cancer The service or supply must be for the treatment of a malignancy Diagnoses secondary to cancer are not covered under this benefit

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

Dental accident The Plan will pay 100 no deductible of reasonable and customary charges for the treatment or repair including root canal therapy and crowns of an accidental injury to sound natural teeth
not from biting or chewing provided the accident occurs while covered by the FEHB Program and the treatment or repair is performed within one year of the accident If treatment or repair to a
child's teeth must be delayed because of the child's age the Plan may extend coverage to a period of not more than three years from the date of the accident provided the request for delay is made
to the Plan within one year of the accident and the child remains covered by the Plan until treatment is completed

The Plan may request dental records including X rays to substantiate the condition of the teeth prior to the accidental injury Charges covered for dental accidents cannot be considered under
Dental Benefits

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Section 5 Benefits continued
Home health care If home health care see definition is precertified see page 34 the Plan will pay 100 of the reasonable and customary charges up to a maximum of 80 per visit for up to 90 visits per
calendar year when the care is an alternative to hospitalization
If the care is not precertified the Plan will pay 100 of the reasonable and customary charges up to a maximum of 40 per visit for up to 40 visits per calendar year when the 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 by a registered nurse RN or a licensed practical nurse LPN

One session of physical occupational or speech therapy provided by a licensed therapist
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 Plan member
The above 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 member's home

Hospice care If hospice care is precertified see page 34 the Plan will pay 100 of the reasonable and customary charges up to a maximum of 7,500 for 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 prescribed by a doctor

If the care is not precertified the Plan will pay 100 of the reasonable and customary charges up to a maximum of 5,500 when a doctor prescribes hospice care

Outpatient surgical The Plan will pay 100 of charges for the use of an outpatient surgical center or other outpatient
facility surgical facility including a doctor's office The doctor's charge for surgery is covered under Surgical Benefits page 13

Renal dialysis The Plan will pay 100 of reasonable and customary charges for covered services and supplies for renal dialysis in or out of the hospital

Skilled nursing If a person is confined in a skilled nursing facility and the confinement is precertified see page
facilities 34 the Plan will for a maximum of 60 days per calendar year pay 100 of the reasonable and customary charges when the confinement is an alternative to hospitalization

If a person is confined in a skilled nursing facility but the confinement is not precertified the Plan will for a maximum of 30 days per calendar year pay 80 of the reasonable and customary
charges when the confinement is an alternative to hospitalization

Vision care The Plan will pay up to 45 per person per calendar year for one routine eye examination including eye refraction if part of the routine exam Please note that the itemized bill must
indicate that the visit is for the purpose of a routine exam

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Section 5 Benefits continued
Prescription Drug Benefits What is covered You may purchase the following medications and supplies prescribed by a physician 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 medication FDA approved prescription drugs and devices for birth control
Ostomy and colostomy supplies
What is not covered Medical supplies such as dressings and antiseptics Drugs and supplies for cosmetic purposes
Nutritional supplements vitamins Fertility drugs after the Plan's payment for the treatment of infertility has met the 5,000
lifetime maximum
Drugs to aid in smoking cessation except under Smoking cessation benefit see page 19 Medication that does not require a prescription under Federal law even if your doctor prescribes

it or a prescription is required under your State law
Drugs to treat sexual dysfunction and impotence

From a pharmacy You may purchase up to a 34 day supply of covered drugs or supplies at a discount through a Caremark Retail Network Pharmacy or pay full price at a non network pharmacy Call
1 800 831 4440 to locate a network pharmacy in your area You pay the cost of a prescription at the time of purchase The expense is reimbursed at 75 after the 250 deductible has been met

To claim Use Plan claim form HCFA 1500 to claim benefits for prescription drugs and supplies you purchased
benefits at any network or non network retail pharmacy You may obtain claim forms by calling
1 800 638 8432 Complete and sign the claim form attach prescription receipts and mail it to Rural Carrier Benefit Plan P O Box 668329 Charlotte NC 28266 8329 Your receipt must show the

patient's name prescription number name of drug prescribing doctor's name date charge and name of pharmacy

By mail If your doctor orders more than a 34 day supply of drugs or covered supplies up to a 90 day supply you may order your prescription or refill by mail from the Rural Carrier Benefit Plan mail order drug
program Caremark will fill your prescription All drugs and supplies covered by the Plan are available under this program except drugs to aid in smoking cessation and fertility drugs

Under the Rural Carrier Benefit Plan mail order drug program if a generic equivalent to the prescribed drug is available Caremark will dispense the generic equivalent instead of the brand name
unless your doctor specifies that the brand name is medically required You pay a 15 copayment for each brand name prescription drug and a 10 copayment for each generic prescription drug or refill
you purchase through the Plan's mail order drug program
Medicare You pay a 5 copayment for each brand name or a 2 copayment for each generic prescription drug
copayment or refill when you are covered by Medicare Part B and use the Plan's mail order drug program

To claim The Plan will send you information on the mail order drug program To use the program
benefits 1 Complete the initial mail order form

2 Enclose your prescription and copayment 3 Mail your order to Caremark P O Box 659572 San Antonio TX 78265 9572

4 Allow approximately two to three weeks for delivery
You'll receive forms for refills and future prescription orders each time that you receive drugs or supplies under this program 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 1 800 831 4440
Drugs from Prescription drugs are also covered at 75 after the 250 deductible has been met under this Plan other sources when they are provided to you by a doctor or covered facility

Purchasing drugs Only prescription drugs and supplies available in the United States and listed above as covered by the when you are in a Plan are eligible for reimbursement when purchased in a foreign country These expenses are
foreign country reimbursed at 75 after the 250 deductible has been met
22 22
22 Page 23 24
Section 5 Benefits continued
Dental Benefits What is covered The Plan will pay for the following services on the Class A and Class B schedules of dental
allowances These lists include all covered services
Class A schedule of dental allowances Preventive care The Plan pays actual charges for up to two visits per person per calendar year up to the amounts

specified below you pay any charges that exceed Plan payment
Oral exam 12.50 Complete X ray series 34.00 Prophylaxis adult 22.00 Panoramic X ray 34.00

Prophylaxis child thru age 14 15.00 Single film X ray 5.50 with fluoride treatment 24.00 Each additional X ray film up to 7 4.00
Space maintainer 88.00 Bitewings 2 films 9.00 Bitewings 4 films 14.00

Class B schedule of dental allowances Restorative care After you pay a deductible of 50 per person per calendar year and any charges that exceed Plan
payment the Plan pays actual charges up to the amounts specified below
Restorations Root canal therapy Amalgam 1 surface deciduous 12.50 One root 106.00

Amalgam 2 surfaces deciduous 18.50 Two roots 126.00 Amalgam 3 or more surfaces deciduous 23.50
Three or more roots 170.00 Amalgam 1 surface permanent 14.00 Gingival curettage per quadrant 26.50

Amalgam 2 surfaces permanent 20.50 Crowns Amalgam 3 or more surface permanent 26.50
Plastic with gold 120.00 Silicate cement 13.50 Porcelain 113.50

Acrylic or plastic 21.50 Porcelain with gold 120.00 Gold 103.50
Gold full cast 120.00 Extractions uncomplicated Gold 3 4 cast 120.00

Single tooth 16.00 Stainless steel 21.50 Each additional tooth 15.00
Dentures Pulp capping direct 9.50 Complete upper or lower 126.00

Pulpotomy vital 21.00 Partial without bar 138.00
Pontics Partial with bar 157.00 Porcelain fused to gold 120.00 Repairs 14.00

Dowel pin 25.00 Relining 40.50
Where this schedule provides for a category of service but does not specifically list a particular procedure belonging in that category the Plan will determine the maximum allowance for that
procedure Services of a dentist are not covered under any other Plan benefit except as described above and on pages 14 and 20

Related benefits
Dental accident For dental accident benefit see page 20

Oral surgery For covered oral surgery see page 14

What is not covered Charges related to orthodontia
Dental procedures involving the preparation of the mouth for dentures including routine tooth extractions

Dental implants
Dental appliances study models splints and other devices or services related to the treatment of TMJ dysfunction

Other dental services not listed as covered
Any service covered under another provision of the Plan

23 23
23 Page 24 25
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 enrollees and family members who are members of this Plan The cost of the benefits described on

this page is not included in the FEHB premium any charges for these services do not count toward any FEHB deductibles out of pocket maximum copayment charges etc These benefits are not subject to the FEHB disputed claims
review procedure
Long term care Long term care is open to NRLCA members their spouse parents and parents in law insurance under the age of 80 Premium rates are based on your age at the time of approval for
coverage Please consult the separate descriptive pamphlet for detailed information
Covers confinements for skilled nursing intermediate nursing and custodial care 100 per day benefit

Covers nonconfinement care for home health care adult day care and respite care 50 per day benefit
Includes return of premium feature
Includes inflation protection option

Term life insurance Term life insurance is open to active postal employees who are members of the NRLCA under age 60 Premium rates are based on your age at time of approval for
coverage and at each renewal date Please consult the separate descriptive pamphlet for detailed information

Provides up to 200,000 of term life insurance coverage in 25,000 multiples
Provides up to 40,000 accidental death and dismemberment coverage
Family life insurance coverage up to 10,000
Living Care benefit for terminally ill enrollees

Long term Long term disability income insurance protects an individual from being unable to disability income work because of an illness on injury Long term disability coverage is available to
insurance active regular rural letter carriers that are members of the NRLCA Premium rates are based on your age and benefit level selected Please consult the separate descriptive
pamphlet for detailed information
Two benefit levels with a waiting period
Replacement of up to 60 of basic pay tax free
Benefits payable to age 65
Premiums payable through payroll allotment

For further information on any of the above benefits contact the NRLCA Insurance Department at

NRLCA Group Insurance Department 1630 Duke Street First Floor
Alexandria VA 22314 3466 1 703 684 5552

Benefits on this page are not part of the FEHB contract
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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 call the Plan at 1 703 684 5552 to report the delay This is also the number to call

and questions for claim forms or advice on filing claims Until you receive your identification card s use your copy of the SF 2809 enrollment form or your annuitant confirmation letter from OPM as
proof of enrollment when you obtain services
If you have a question concerning Plan benefits contact the Carrier at 1 800 638 8432
Claim forms will be furnished with your identification cards Claim forms will also be furnished with all claim payments Additional forms may be obtained by writing to the Plan at

1630 Duke Street First Floor Alexandria VA 22314 3466 or calling 1 800 638 8432

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
Date s on which 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 or Medicare Summary Notice MSN from any primary payer must be sent with your claim

Bills for private duty nurses must show that the nurse is a registered or licensed practical nurse and must include nursing notes
Claims for rental or purchase of durable medical equipment private duty nursing and physical occupational and speech therapy require a written statement from the doctor
specifying the medical necessity for the service or supply and the length of time needed
Claims for prescription drugs and medicines that are not ordered through the mail order drug program must include receipts that include the prescription number name of drug

prescribing doctor's name date charge and name of the pharmacy
Claims for overseas foreign services should include an English translation Charges should be converted to U S Dollars using the exchange rate applicable at the time the

expense was incurred
If the claim involves hospitalization the hospital billing statement must show or the hospital must advise the type of accommodations private semiprivate etc If a private

room is used the billing statement must show the average semiprivate rate
Canceled checks cash register receipts or balance due statements are not acceptable
Complete a claim form HCFA 1500 Note the name of the insured the same as it appears on the ID card Be sure to answer all questions or mark Not Applicable N A on those which

do not apply every time you file a claim
The attending doctor or dentist must complete the statement on the HCFA 1500 or furnish another statement which includes the name of the patient the diagnosis dates of treatment

itemized charges and the Federal Tax ID number of the doctor or dentist There is no separate prescription drug or dental claim form

After completing claim form HCFA 1500 and attaching the doctor's or dentist's statement and all related itemized bills send claims to
Rural Carrier Benefit Plan P O Box 668329
Charlotte NC 28266 8329 Claims toll free telephone number 1 800 638 8432
Plan Administrative Office telephone number 1 703 684 5552

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Section 6 How to File a Claim continued
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 all medical bills including
those being accumulated to satisfy a deductible In most instances they will serve as evidence of your claim The Carrier will not provide duplicate or year end statements

Submit claims Claims must be filed within 90 days after the expense for which the claim is being made was promptly incurred To avoid delays in payment submit claims as expenses are incurred Do not hold
claims until the end of the year Expenses are incurred on the date on which the service or supply is received No benefits are payable for claims submitted to the Plan more than two
years from the date the expense is incurred unless timely filing was prevented by administrative operations of Government or legal incapacity provided the claim was submitted
as soon as reasonably possible
A finding of custodial care by the Plan does not exclude benefits for all services and supplies Some services such as prescription drugs X rays and lab tests may still be covered ALL

BILLS SHOULD BE ROUTINELY SUBMITTED TO THE PLAN FOR CONSIDERATION

Once benefits have been paid there is a three year limitation on the reissue of uncashed checks

Direct payment to An assignment to direct benefit payments to the hospital or doctor may be made by completing hospital or provider an assignment form furnished by the hospital or doctor or by completing the assignment
of care statement on claim form HCFA 1500

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

26 26
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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 following
Services drugs or supplies that are not medically necessary
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 abortion except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape

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

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

Services drugs or supplies furnished without charge except as described on page 31 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 or supplies furnished by immediate relatives or household members such as spouse parents child brother or sister by blood marriage or adoption
Services or supplies furnished or billed by a noncovered facility except that medically necessary prescription drugs are covered
Charges for services and supplies that are not reasonable and customary
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 or coinsurance the

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

Charges the enrollee or Plan has no legal obligation to pay such as excess charges for an annuitant age 65 or older who is not covered by Medicare Part A and or B see pages 31 and 32 doctor
charges exceeding the amount specified by the Department of Health and Human Services when benefits are payable under Medicare limiting charge or State premium taxes however applied

Acupuncture
Custodial care
Preventive medical care and services including periodic checkups and well child care after age 24 months associated X ray and lab tests except as provided under Other Medical Benefits pages 18

and 19 and Additional Benefits page 20
Weight control or any treatment of obesity except surgery for morbid obesity ileojejunal balloon or gastric shunt procedures

Programs for smoking cessation and related drugs even if prescribed by a doctor except as provided under Other Medical Benefits page 19
Inpatient private duty nursing
Any services rendered related to a learning disability
Chelation therapy except for acute arsenic gold mercury or lead poisoning
Breast implants except after mastectomy as provided on pages 15 and 18 injections of silicone or other substances and all related charges

Nonmedical services such as social services and recreational educational visual and speech therapy except as provided for on pages 18 and 19
Hearing aids and examinations for them
Eyeglasses and contact lenses except as covered under Other Medical Benefits on page 18
Non surgical treatment of temporomandibular joint TMJ dysfunction including dental appliances study models splints and other devices and

Services drugs or supplies for cosmetic purposes 27 27
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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 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
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

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 entitled to benefits from both this Plan and Medicare You must disclose information about Medicare

coverage including your enrollment in a Medicare prepaid plan to this Carrier this applies whether or not you file a claim under Medicare You must also give this Carrier authorization
to obtain information about benefits or services denied or paid by Medicare when they request it It is also important that you inform the Carrier about other coverage you may have as this
coverage may affect the primary secondary status of this plan and Medicare see page 31
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 or

4 The patient you or a covered family member is under age 65 and eligible for Medicare solely on the basis of disability and you are employed by the Federal Government

For purposes of this section employed by the Federal Government means that you are eligible for FEHB coverage based on your current employment and that you do not hold an
appointment described under Rule 6 of the following Medicare is primary section

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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 65 or over and a you are a Federal judge who retired under title 28 of the U S C b you are a Tax Court judge who retired under Section 7447 of title 26 of the
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 Programs has determined that you are unable to return to duty

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

When Medicare is primary When Medicare is primary all or part of your Plan deductibles and coinsurance will be waived as follows
Inpatient Hospital Benefits If you are enrolled in Medicare Part A the Plan will waive the deductible and coinsurance
Surgical Benefits If you are enrolled in Medicare Part B the Plan will waive the coinsurance
Mental Conditions Substance Abuse Benefits If you are enrolled in Medicare Part A the Plan will waive the deductible and coinsurance

Other Medical Benefits If you are enrolled in Medicare Part B the Plan will waive the deductible and coinsurance applicable to medical care Note Medicare does not cover
outpatient prescription drugs therefore neither the deductible nor the coinsurance for prescription drugs is waived

Prescription Drugs If you are enrolled in Medicare Part B this Plan will reduce the copayment you pay under the Rural Carrier mail order drug program from 10 to 2 per
prescription for generic prescriptions and from 15 to 5 for brand name prescriptions
Dental Benefits A person enrolled in Medicare is required to satisfy the dental deductible
When Medicare is the primary payer this Plan will limit its payment to an amount that supplements the benefits that would be payable by Medicare regardless of whether or not

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

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

When you also enroll in When you are enrolled in a Medicare Choice plan while you are a member of this Plan you a Medicare Choice plan 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

29 29
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Section 8 Limitations Rules that affect your benefits continued
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 Medicare approved amount
Doctors who do not participate with Medicare are not required to accept direct payment or assignment from Medicare Although they can bill you for more than the amount Medicare would

pay Medicare law the Social Security Act 42 U S C sets a limit on how much you are obligated to pay This amount called the limiting charge is 115 of the Medicare approved amount
Under this law if you use a doctor who does not accept assignment for the claim the doctor is permitted to bill you after the Plan has paid only if the Medicare and Plan payments combined do
not total the limiting charge Neither you nor your FEHB Plan is liable for any amount in excess of the Medicare limiting charge for charges of a doctor who does not participate with Medicare
The Medicare Summary Notice MSN form will have more information about this limit
If your doctor does not participate with Medicare and asks you to pay more than the limiting charge ask the doctor to reduce the charge or report him or her to the Medicare carrier that sent

you the Medicare MSN statement In any case a doctor who does not participate with Medicare is not entitled to payment of more than 115 of the Medicare approved amount

How to claim benefits In most cases when both Medicare and this Plan cover services 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 Carrier 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 Carrier You may call the Carrier at 1 800 638 8432 to find out if your claims are being electronically
filed If they are not you should initially submit your claims to Medicare and after Medicare has paid its benefits the Carrier will consider the balance of any covered expenses upon receipt of the
itemized bill and Medicare Summary Notice MSN statement The Carrier will not process your claim without knowing whether you have Medicare and if you do without receiving the Medicare
MSN statement

Other group When anyone has coverage with us and with another group health plan it is called double coverage insurance 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 After the first plan pays we will pay either what is left of the reasonable and customary charge or our regular

benefit whichever is less We will not pay more than the reasonable and customary charge
Remember Even if you do not file a claim with your other plan you must still tell us that you have double coverage

When others are Subrogation applies when you are sick or injured as a result of the act or omission of another responsible for person or party Subrogation describes the Plan's right to recover any payments made to you or
injuries your dependent by a third party's insurer because of an injury or illness caused by a third party Third party means another person or organization

If you or your dependent receive Plan benefits and have a right to recover damages from a third party the Plan is subrogated to this right All recoveries from a third party whether by lawsuit
settlement or otherwise must be used to reimburse the Plan for benefits paid Any remainder will

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Section 8 Limitations Rules that affect your benefits continued
be yours or your dependents The Plan's share of the recovery will not be reduced because of attorney's fees or because you or your dependent has not received the full damages claimed
unless the Plan agrees in writing to a reduction
You must promptly advise the Plan whenever a claim is made against a third party with respect to any loss for which Plan benefits have been or will be paid You or your dependent

must execute any assignments liens or other documents and provide information as the Plan requests Plan benefits may be withheld until documents or information is received

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 We are entitled to be reimbursed by OWCP or the similar agency for
benefits paid by us that were later found to be payable by OWCP or the agency
Medicaid We pay first if both Medicaid and this Plan cover you
Other Government We do not cover services and supplies that a local State or Federal Government agency Agencies directly or indirectly pays for

Overpayments The Carrier will make reasonably diligent efforts to recover benefit payments made erroneously but in good faith and may apply subsequent benefits otherwise payable to offset
any overpayments
Limit on your costs The information in the following paragraphs applies to you when 1 you are not covered by if you're 65 or older and either Medicare Part A hospital insurance or Part B medical insurance or both 2 you are
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
that confers FEHB coverage
Inpatient If you are not covered by Medicare Part A are age 65 or older or become age 65 while hospital care receiving inpatient hospital services and you receive care in a Medicare participating hospital
the law 5 U S C 8904 b requires the Plan to base its payment on an amount equivalent to the amount Medicare would have allowed if you had Medicare Part A This amount is called
the equivalent Medicare amount After the Plan pays the law prohibits the hospital from charging you for covered services after you have paid any deductibles coinsurance or
copayments you owe under the Plan Any coinsurance you owe will be based on the equivalent Medicare amount not the actual charge You and the Plan together are not legally
obligated to pay the hospital more than the equivalent Medicare amount
The Carrier's explanation of benefits EOB will tell you how much the hospital can charge you in addition to what the Plan paid If you are billed more than the hospital is allowed to

charge ask the hospital to reduce the bill If you have already paid more than you have to pay ask for a refund If you cannot get a reduction or refund or are not sure how much you
owe call the Plan at 1 800 638 8432 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

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Section 8 Limitations Rules that affect your benefits continued
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 The Plan will
base its payment on the lower of these two amounts and you are responsible only for any deductible or coinsurance

If your physician participates with Medicare the Plan will base its regular benefit payment on the Medicare approved amount For instance under this Plan's surgery benefit the Plan will
pay 85 of the Medicare approved amount You will only be responsible for any deductible and coinsurance equal to 15 of the Medicare approved amount

If your physician does not participate with Medicare the Plan will still base its payment on the Medicare approved amount However in most cases you will be responsible for any
deductible the coinsurance amount and any balance up to the limiting charge amount 115 of the Medicare approved amount

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

charge ask the hospital or physician to reduce the bill If you have already paid more than you have to pay ask for a refund If you cannot get a reduction or refund or are not sure how
much you owe call the Plan at 1 800 638 8432 for assistance

Section 9 Fee for Service plan facts
Protection Against Catastrophic Costs
Catastrophic protection For those services with coinsurance the Plan pays 100 of reasonable and customary charges for the remainder of the calendar year after the calendar year deductible is met when out ofpocket

expenses in that calendar year exceed 2,000 per person or 2,500 per family in PPO benefits The out of pocket expense limits for Non PPO benefits are 2,500 per person or
3,000 per family Any expenses incurred through PPO or Non PPO benefits apply toward both catastrophic limits

Out of pocket expenses for the purposes of this benefit are
The 10 PPO and the 15 Non PPO you pay for Surgical Benefits
The 20 Non PPO you pay for Inpatient Hospital Benefits
The 15 PPO and 25 Non PPO you pay for Other Medical Benefits
The 250 you pay toward the Other Medical Benefits calendar year deductible
The 200 non PPO you pay toward the first hospital admission deductible under Inpatient Hospital Benefits

The following cannot be included in the accumulation of out of pocket expenses
Expenses in excess of reasonable and customary charges or maximum benefit limitations
The 15 copayment PPO for doctor office visits
Expenses for mental conditions substance abuse or dental care
Expenses incurred for medications ordered through the Rural Carrier mail order drug program

Expenses for non covered services and supplies
Expenses for confinement in a skilled nursing facility and
Any amounts you pay because benefits have been reduced for non compliance with this Plan's cost containment requirements see page 34

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Section 9 Fee for Service plan facts continued
Mental Conditions For Mental conditions after the 20 you pay for inpatient care plus the 200 deductible Substance Abuse total 8,000 in a calendar year for an individual the Plan will then pay 100 of covered
Benefit hospital charges for that individual for the remainder of the calendar year

Carryover If you changed to this Plan during open season from a plan with a catastrophic protection benefit and the effective date of the change was after January 1 any expenses that would have
applied to that plan's catastrophic protection benefit during the prior year will be covered by your old plan if they are for care you got in January before the effective date of your coverage
in this Plan If you have already met the covered out of pocket maximum expense level in full your old plan's catastrophic protection benefit will continue to apply until the effective
date If you have not met this expense level in full your old plan will first apply your covered out of pocket expenses until the prior year's catastrophic level is reached and then apply the
catastrophic 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

Precertification
Precertify before Precertification is not a guarantee of benefit payments Precertification of an inpatient admission 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
To precertify a scheduled admission
You your representative your doctor or your hospital must call Mutual of Omaha's Care Review Unit at least seven days prior to admission 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 proposed treatment or
surgery name of hospital or facility name and phone number of admitting doctor and number of planned days of confinement

Mutual of Omaha's Care Review Unit will then tell the doctor and hospital the number of approved days of confinement for the care of the patient's condition Written confirmation of
the Carrier's certification decision will be sent to you your doctor and the hospital If the length of stay needs to be extended follow the procedures below

Need additional 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 not be medically necessary by the Carrier during the claim review

You don't need Medicare Part A or another group health insurance policy is the primary payer for the to certify an hospital confinement see pages 29 and 30 Precertification is required however when
admission when Medicare hospital benefits are exhausted prior to using lifetime reserve days
You are confined in a hospital outside the United States

Maternity or When there is an unscheduled maternity admission or an emergency admission due to a emergency admissions condition that puts the patient's life in danger or could cause serious damage to bodily
function 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 inpatient benefits payable for the admission will be reduced by 500

Newborn confinements that extend beyond the mother's discharge date must also be certified You your representative the doctor or hospital must request certification for the newborn's
continued confinement within two business days following the day of the mother's discharge

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Section 9 Fee for Service plan facts continued
Other considerations An early determination of need for confinement precertification of the medical necessity of inpatient admission is binding on the Carrier unless the Carrier is misled by the information

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

If you do not precertify If precertification is not obtained before admission to the hospital or within two business days following the date of a maternity or emergency admission or in the case of a newborn the
mother's discharge a medical necessity determination will be made at the time the claim is filed If the Carrier determines that the hospitalization was not medically necessary the
inpatient hospital benefits will not be paid However medical supplies and services otherwise payable on an outpatient basis will be paid

If the claim review determines that the admission was medically necessary any benefits payable according to all of the terms of this brochure will be reduced by 500 for failing to
have the admission precertified
If the admission is determined to be medically necessary but part of the length of stay was found not to be medically necessary inpatient hospital benefits will not be paid for the portion
of the confinement that was not medically necessary However medical services and supplies otherwise payable on an outpatient basis will be paid

Precertify home health When home health care hospice care or skilled nursing care are prescribed by a doctor you care hospice care and your representative the doctor the home health agency hospice agency or skilled nursing
skilled nursing care facility must telephone Mutual of Omaha's Care Review Unit at 1 800 228 0286 for a predetermination that based on the information given the care meets the medical necessity
requirements of the Carrier Otherwise benefits payable for the care will be reduced

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Section 9 Fee for Service plan facts continued
Definitions Accidental injury An injury caused by an external force such as a blow or a fall and that requires immediate
medical attention Animal bites and poisonings are also included as is 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 into a hospital admission or other covered facility until discharge In counting days of inpatient care the date of entry and the date of discharge are counted as the
same day

Assignment An authorization by an enrollee or spouse for the Carrier to issue payment of benefits directly to the provider The Carrier reserves the right to pay the member directly for all covered
services

Calendar year January 1 through December 31 of the same year For new enrollees the calendar year begins on the effective date of their enrollment and ends on December 31 of the same year

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 which is a significant deviation from the common form or norm For purposes of this Plan congenital anomalies include cleft lips cleft palates birth
marks webbed fingers or toes and other conditions that the Carrier may determine to be congenital anomalies In no event will the term congenital anomaly include conditions relating
to teeth or intra oral structures supporting the teeth
Cosmetic surgery Any operative procedure or any portion of a procedure performed primarily to improve physical appearance and or treat a mental condition through change in bodily form

Custodial care Treatment or services regardless of who recommends them or where they are provided that could be rendered safely and reasonably by a person not medically skilled or that are
designed mainly to help the patient with daily living activities These activities include but are not limited to

1 personal care such as help in walking getting in and out of bed bathing eating by spoon tube or gastrostomy exercising dressing
2 homemaking such as preparing meals or special diets
3 moving the patient
4 acting as companion or sitter
5 supervising medication that can usually be self administered or
6 treatment or services that any person may be able to perform with minimal instruction including but not limited to recording temperature pulse and respirations or administration

and monitoring of feeding systems
The Carrier 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

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Section 9 Fee for Service plan facts continued
Effective date The date the benefits described in this brochure are effective
1 January 1 for continuing enrollments or
2 for new enrollees in the Plan the effective date of enrollment is determined by the employing office or retirement system of the enrollee

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 Health care coverage that a member is eligible for because of employment by membership in coverage 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
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 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 or is
qualified and could be 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 a Carrier approved independent hospice administration
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 care that the
covered person secures within 5 days after the onset Medical emergencies include deep cuts broken bones heart attacks cardiovascular accidents strokes poisonings loss of
consciousness or respiration convulsions and such other acute conditions as may be determined by the Carrier 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 Carrier determines
1 are appropriate to diagnose or treat the patient's condition illness or injury
2 are consistent with standards of good medical practice in the United States
3 are not primarily for the personal comfort or convenience of the patient the family or the provider

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

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 Carrier or disorders listed in the ICD requiring treatment for abuse of or dependence upon substances such as alcohol
narcotics or hallucinogens
Morbid obesity A condition in which an individual
1 is greater than 100 pounds or 100 over the standard weight as determined by the Carrier's underwriter with complicating medical condition s and

2 has been so for at least five years despite documented unsuccessful attempts to reduce weight under a diet and exercise program monitored by a doctor

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Section 9 Fee for Service plan facts continued
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 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 Carrier'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 physician 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 that is whole or properly restored and is without impairment periodontal disorders or other dental disorders and is not in need of the treatment provided for any reason other than an
accidental injury

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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 and its networks of 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 and

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 1 800 638 8432 or write to Rural Carrier Benefit Plan
1630 Duke Street First Floor Alexandria VA 22314 3466

You may also contact us by fax at 1 703 684 9627 or visit our website at www nrlca 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 need to make an informed decision about FEHB Program
When you may change your enrollment
How you can cover your family member
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 and The benefits in this brochure are effective on January 1 If you are new to this plan your 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 you retire you can usually stay in the FEHB Program Generally you must have been when I 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 your unmarried dependent children under age 22 including any foster or step children your
and 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

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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 Workers Compensation Programs OWCP when coordinating benefit payments and

subrogation claims
Your physician s when reviewing your prescription drug usage under the Plan's prescription drug program

Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions
OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your identity or

OPM when reviewing a disputed claim or defending litigation about a claim
Information for new members Identification cards We will send you an Identification ID card Use your copy of the Health Benefits

Registration 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 deductible Your old plan's deductible continues until our coverage begins under my old plan
Pre existing conditions We will not refuse to cover the treatment of a condition that you or a family member had 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 spouse If you are divorced from a Federal employee or annuitant you may not continue to get coverage benefits under your spouse's coverage 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 spouse's employing or retirement office to get more information about your coverage
choices

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

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

passed

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Section 10 FEHB Facts continued
You pay the total premium and generally a 2 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 your premium
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 they become eligible for TCC or receive this notice whichever is later

Former spouses You or your former spouse must notify your employing or retirement office within 60 days of one of these qualifying events
Divorce or
Loss of spouse equity coverage within 36 months after the divorce

Your employing or retirement office will then send your former spouse information about enrolling in TCC Your former spouse must enroll within 60 days after the event which

qualifies them for coverage or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notifies 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 the 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 nor will we You must apply in writing to us within 31 days after
you are no longer eligible for coverage Send your request to
NRLCA Insurance Department 1630 Duke Street First Floor

Alexandria VA 22314 3466
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 information in the certificate

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

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

Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 1 800 638 8432 and explain the situation
If we do not resolve the issue call or write

THE HEALTH CARE FRAUD HOTLINE 1 202 418 3300

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

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

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

Your agency may also take administrative action against you

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Notes
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Summary of Benefits for the Rural Carrier Benefit Plan 2000
Do not rely on this chart alone All benefits are subject to the definitions limitations and exclusions set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or change your enrollment in

this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of this brochure All items below with an asterisk are subject to the 250 calendar year deductible

Benefits Plan pays provides Page
Inpatient Hospital PPO 100 of hospital charges no deductible 11,12 care Non PPO After 200 deductible per person for the first admission in a calendar

year 100 of room and board and 80 of all other covered hospital charges 11,12
Surgical PPO 90 of the provider's negotiated fee 13,14 Non PPO 85 of reasonable and customary charges 13,14

Medical PPO 85 of the provider's negotiated fee 15 copayment per doctor office visit no deductible 18 20
Non PPO 75 of reasonable and customary charges 18 20
Maternity Same benefits as for illness and injury 15,16
Mental conditions PPO 100 of covered hospital charges no deductible 16,17 Non PPO After a 200 deductible per person for the first admission in a calendar

year 100 of room and board and 80 of other covered hospital charges 16,17
Substance abuse PPO Up to 6,000 per treatment program including aftercare in an accredited alcohol or drug abuse treatment facility limited to two treatment programs

per lifetime 17 Non PPO Up to 5,500 per treatment program including aftercare in an
accredited alcohol or drug abuse treatment facility limited to two treatment programs per lifetime 17

Outpatient Hospital PPO 100 for surgery facility 85 of other hospital charges 18,21 care Non PPO 100 of reasonable and customary charges for surgery facility
75 of other hospital charge 18,21
Surgical PPO 90 of provider's negotiated fee 13,14 Non PPO 85 of reasonable and customary charges 13,14

Medical PPO 85 of provider's negotiated fee 18 20 Non PPO 75 of reasonable and customary charges 18 20
Maternity Same benefits as for illness and injury 15,16
Home health care 100 of the reasonable and customary charges up to a maximum of 80 per visit for up to 90 visits in a calendar year 21

Mental conditions Up to 75 per session not subject to deductible or coinsurance 17
Substance abuse PPO Up to 6,000 for an aftercare treatment program 17 Non PPO Up to 5,500 for an aftercare treatment program 17

Emergency care PPO Up to 500 of charges for treatment of injury that was incurred within 5 days of the accidental injury 20
Non PPO Up to 300 of charges for treatment of injury that was incurred within 5 days of the accidental injury 20

Prescription drugs The Plan pays 75 and you pay 25 of reasonable and customary charges Under the mail order drug program you pay 10 generic 15 brand name per prescription
or refill 2 generic 5 brand name if you are covered by Part B of Medicare 22
Dental care Benefits for preventive and restorative services listed on dental schedules 23

Additional benefits Hospice care Home Health care Vision care Cancer treatment Childhood immunizations Renal dialysis Skilled nursing facility care Dental accident 20,21

Out of pocket maximum 100 of covered charges under Inpatient Hospital Surgical and Other Medical Benefits after expenses reach 2,000 PPO 2,500 Non PPO out of pocket
per individual or 2,500 PPO 3,000 Non PPO per family in a calendar year or after you spend 8,000 on covered hospital charges under Mental conditions for one
person in a calendar year 32,33

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Authorized for Distribution by the
UNITED STATES OFFICE OF PERSONNEL MANAGEMENT

2000 Rate Information for
Rural Carrier Benefit Plan

Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the FEHB Guide for that category or contact the agency that maintains your health benefits enrollment
Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates referred to as Category A rates and Category B rates will apply for certain career employees If you are a career
postal employee but not a member of a special postal employment class refer to the category definition in The Guide to Federal Employees Health Benefit Plans for United States Postal Employees RI 70 2 to determine
which rate applies
Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes or associate members of any postal employee organization Such persons not subject to postal rates must refer to
the applicable Guide to Federal Employees Health Benefits Plans

Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Code Gov't Your Gov't Your USPS Your USPS Your
Enrollment Share Share Share Share Share Share Share Share

High Option
Self Only 381 n a n a 170.80 86.71 93.06 25.79 93.26 25.59

High Option
Self and Family 382 n a n a 381.27 143.71 207.74 34.56 201.02 41.28 44

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