Pages 1--28 from Untitled

For changes benefits in
4 see
pages 3

Serving Most of Washington State and Northern Idaho
Enrollment in this Plan is limited see page 5 for requirements

Western Washington
Enrollment code
541 Self only
542 Self and family

Eastern Central Washington and Northern Idaho
Enrollment codes This plan has commendable accreditation
VR1 Self only from the NCQA See the FEHB Guide
VR2 Self and family for more information on NCQA

Special Notice This Plan has eliminated a portion of its Service Area for 2000 If you are enrolled in this Plan and
live or work in one of the following areas you must select another plan during Open Season to continue to receive
full benefits the Washington counties of Adams Chelan Clallam Douglas Ferry Grant Klickitat Lincoln
Okanogan Pend Oreille and Stevens and the Idaho counties of Benewah Bonner and Shoshone If you live or
work in one of these areas and do not select another FEHB Plan you must travel to a county in the Service Area
and be seen by a Plan provider in order to receive full Plan benefits

Visit the OPM website at http www opm gov insure
and
our Plan's website for Western Washington at http www ghc org
and
our Plan's website for Eastern Central Washington and Northern Idaho at
http www ghnw org

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

RI 73 012 1
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GROUP HEALTH COOPERATIVE 2000
Table of Contents
Page
Introduction 1

Plain language 1
How to use this brochure 2
Section 1 Health Maintenance Organizations 3
Section 2 How we change for 2000 3 4
Section 3 How to get benefits 5 7
Section 4 What to do if we deny your claim or request for service 7 8
Section 5 Benefits 9 17
Non FEHB Benefits 18
Section 6 General exclusions Things we don't cover 19
Section 7 Limitations Rules that affect your benefits 19 20
Section 8 FEHB FACTS 20 23
Inspector General Advisory Stop Healthcare Fraud 23
Summary of benefits Inside back cover
Premiums Back cover

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GROUP HEALTH COOPERATIVE 2000
Introduction
Group Health Cooperative of Puget Sound
521 Wall Street
Seattle Washington 98121

This brochure describes the benefits you can receive from Group Health Cooperative under its contract CS 1043 with the Office of
Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law This brochure is the official
statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this brochure If you
are enrolled for Self and Family coverage each eligible family member is also entitled to these benefits

OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on
pages 3 4 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 Group Health Cooperative or GHC as this Plan throughout this brochure even though in other legal documents you will see
a plan referred to as a carrier

These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year

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GROUP HEALTH COOPERATIVE 2000
How to use this brochure
This brochure has eight 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 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs 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 services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not
to pay for your claim or to deny your request for a service

5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find information
about non FEHB benefits

6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB FACTS Read this for information about the Federal Employees Health Benefits FEHB Program

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GROUP HEALTH COOPERATIVE 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and other
providers that contract with us These providers coordinate your health care services The care you receive includes preventative care
such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury

When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay copayments
and coinsurance listed in this brochure When you receive emergency services you may have to submit claim forms

You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change plans
because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider will be available and or
remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of treatment

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

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

If you have a chronic or disabling condition and your provider leaves the Plan at our request you may
continue to see your specialist for up to 90 days If your provider leaves the Plan and you are in the
second or third trimester of pregnancy you may be able to continue seeing your OB GYN until the
end of your postpartum care You have similar rights if this Plan leaves the FEHB program See
Section 3 How to get benefits for more information

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 Plan Your share of the non postal premium for Enrollment Code 54 will increase by 12.5 for Self Only and by 11.5 for Self and Family and for Enrollment Code VR it will increase by 3.7 for Self Only

and by 4.8 for Self and Family
The Plan's copay for a Primary Care Physician office visit has increased from 5 to 10 This increase
applies to visits for short term rehabilitative therapy diagnosis and treatment of infertility chiropractic
services podiatric services naturopathic services acupuncture services cardiac rehabilitation
and routine eye examinations and refractions See pages 9 10 and 11

The Plan now covers durable medical equipment such as wheelchairs and hospital beds subject to a
member copay of 20 of charges Previously there was no coverage for durable medical equipment
See page 11

The Plan now covers prosthetic devices such as artificial limbs subject to a member copay of 20 of
charges Previously there was no coverage for prosthetic devices such as artificial limbs See page
11

The Plan now provides coverage for orthopedic appliances such as braces subject to a member
copay of 20 of charges Previously orthopedic appliances were subject to a member copay of 50
of charges See page 11

Oxygen and oxygen equipment for home use is now a part of the durable medical equipment benefit
and as such subject to a member copay of 20 of charges Previously oxygen and oxygen equipment
for home use was covered at 100 See page 11

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GROUP HEALTH COOPERATIVE 2000
Section 2 How we change for 2000 continued
Ostomy supplies necessary for the removal of bodily secretions or waste through an artificial opening
is now part of the prosthetic device benefit and as such subject to a member copay of 20 of charges
Previously ostomy supplies were covered at 100 See page 11

External breast protheses post mastectomy bras and their replacements are now a part of the prosthetic
devices benefit and as such subject to a member copay of 20 of charges Previously external
breast prostheses were limited to one every two years and post mastectomy bras were limited to two
2 every six 6 months and were subject to a member copay of 50 of charges See page 11

Nasal CPAP devices are now a part of the durable medical equipment benefit and as such subject to
a member copay of 20 of charges Previously nasal CPAP devices were subject to a member copay
of 50 of charges See page 11

The Plan now covers insulin pumps and diabetic monitoring equipment as a part of the durable medical
equipment benefit and as such subject to a member copay of 20 of charges Previously insulin
pumps and diabetic monitoring equipment were covered under the Prescription Drug Benefit and
subject to the 7 copay See page 15

The hospice care benefit can provide coverage for drugs biologicals medical appliances and supplies
that are used primarily for the relief of pain and symptom management Previously these items
were not listed in the hospice care benefit See page 12

Chiropractic coverage excludes services not listed in the Plan's protocol including but not limited to
supportive care provided primarily to maintain the level of correction already achieved care given
primarily for the convenience of the member care given on a non acute asymptomatic basis or
charges for office visits other than the initial evaluation Previously the brochure did not list these
chiropractic exclusions See page 11

The out of pocket maximum or catastrophic limit for services provided or arranged by the Plan for a
Self Only enrollment will increase from 750 to 1,000 and for a Self and Family enrollment the
increase will be from 1,500 to 2,000 See page 5

The member's 20 copay for covered inpatient mental health care now applies to the increase in the
out of pocket maximum or catastrophic limit of 1,000 for a Self Only enrollment and 2,000 for a
Self and Family enrollment Previously the member's 20 copay applied to the 750 out of pocket
maximum or catastrophic limit for a Self Only enrollment and 1,500 for a Self and Family enrollment
See page 14

The Plan has eliminated a portion of its Service Area for 2000 If you are enrolled in this Plan and live
or work in one of the following areas you must select another plan during Open Season to continue to
receive full benefits the Washington counties of Adams Chelan Clallam Douglas Ferry Grant
Klickitat Lincoln Okanogan Pend Oreille and Stevens and the Idaho counties of Benewah Bonner
and Shoshone If you live or work in one of these areas and do not select another FEHB Plan you
must travel to a county in the Service Area and be seen by a Plan provider in order to receive full Plan
benefits See front cover and page 5

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GROUP HEALTH COOPERATIVE 2000
Section 3 How to get benefits
What is this Plan's To enroll with us you must live or work in our service area This is where our providers practice Our service area service area is

In Western Washington The counties of Island King Kitsap Lewis Mason Pierce San Juan Skagit Snohomish Thurston and Whatcom the following cities in Grays Harbor County Elma 98541 Malone 98559 McCleary
98557 Oakville 98568 Porter 98573 and the following cities in Jefferson County Brinnon
98320 Chimacum 98325 Gardner 98334 Hadlock 98339 Nordland 98358 Port Ludlow
98365 Port Townsend 98368 and Quilcene 98376 which are east of a line drawn southward from
Port Angeles

In Central and Spokane county and those counties surrounding Spokane within a 70 mile radius of downtown Eastern Washington Spokane Benton Columbia Franklin Kittitas Walla Walla Whitman and Yakima

In Northern Idaho The counties of Kootenai and Latah
You may also enroll with us if you live or work in the following places
In Washington The counties of Grays Harbor and Jefferson
Ordinarily you must get your care from providers who contract with us If you receive care outside our
service area we will pay only for emergency services as described on pages 12 and 13 or those services
covered under Benefits Available Away From home described on page 17 We will not pay for any other
health care services

If you or a covered family member move outside of our service area you can enroll in another plan If
your dependents live out of the area for example if your child goes to college in another state you
should consider enrolling in a fee for service plan or an HMO that has agreements with affiliates in
other areas If you or a family member move you do not have to wait until Open Season to change plans
Contact your employing or retirement office

Plan members who temporarily reside outside the service area of this Plan may have access to care with
Plans that have Reciprocity Agreements with this Plan The Plans are as follows Kaiser Permanente
Plans the American Association of Health Plans AAHP and Alliance of Community Health Plans
ACHP If you need services when out of the area and are in the service area of a Kaiser Permanente
Plan you may obtain care from any Kaiser Permanente provider medical office or medical center If
you plan to travel and wish to obtain more information about the benefits available to you please call
Customer Service at 888 901 4636

How much do I pay You must share the cost of some services This is called either a copayment a set dollar amount or for services coinsurance a set percentage of charges Please remember you must pay this amount when you receive

services except for emergency care
After you pay 1,000 in copayments or coinsurance for one family member or 2,000 for two or more
family members you do not have to make any further payments for certain services for the rest of the
year This is called a catastrophic limit However copayments or coinsurance for Infertility treatment
services devices equipment and supplies dental care the 100 non Plan emergency care deductible
the 20 coinsurance for ambulance services or the outpatient mental health care copayment do not
count toward these limits and you must continue to make these payments

Be sure to keep accurate records of your copayments and coinsurance since you are responsible for
informing us when you reach the limits

Do I have to You normally won't have to submit claims to us unless you receive emergency services from a provider submit claims who doesn't contract with us If you file a claim please send us all of the documents for your claim as

soon as possible You must submit claims by December 31 of the year after the year you received the
service Either OPM or we can extend this deadline if you show that circumstances beyond your control
prevented you from filing on time

Who provides my Group Health Cooperative of Puget Sound is a Mixed Model Prepayment MMP plan The Plan health care provides medical care by doctors nurse practitioners and other skilled medical personnel working as

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GROUP HEALTH COOPERATIVE 2000
Section 3 How to get benefits continued
medical teams Specialist in most major specialties are available as part of the medical teams for
consultation and treatment

For Central and Eastern Washington and Northern Idaho and Whatcom Division members only All
participating doctors are established medical practitioners who provide routine care within their private
office settings in the community

The first and most important decision each member must make is the selection of a primary care doctor
The decision is important since it is through this doctor that all other health services particularly those
of specialists are obtained It is the responsibility of your primary care doctor to obtain any necessary
authorizations from the Plan before referring you to a specialist or making arrangements for hospitalization
Services of other providers are covered only when there has been a written referral by the
member's primary care doctor with the following exception a woman may see a participating General
and Family Practitioner Physician's Assistant Gynecologist Certified Nurse Midwife Doctor of Osteopathy
Obstetrician and Advanced Registered Nurse Practitioner who provide women's health care
services directly without a referral from their primary care doctor for medically appropriate maternity
care covered reproductive health services preventive care and general examination gynecological care
and medically appropriate follow up visits for the above services If your chosen provider diagnoses a
condition that requires more extensive covered care outside the practice scope of your women's health
care provider the primary care doctor must be contacted for authorization and care coordination

What do I do if my Call us We will help you select a new one primary care physician

leaves the Plan
What do I do if I need to Talk to your Plan physician If you need to be hospitalized your primary care physician or specialist go into the hospital will make the necessary hospital arrangements and supervise your care

What do I do if I'm in the First call our customer service department at 888 901 4636 If you are new to the FEHB Program we hospital when I join will arrange for you to receive care If you are currently in the FEHB Program and are switching to us
this Plan your former plan will pay for the hospital stay until
You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first

These provisions only apply to the person who is hospitalized

How do I get specialty care Your primary care physician will arrange your referral to a specialist
If you need to see a specialist frequently because of a chronic complex or serious medical condition
your primary care physician will develop a treatment plan that allows you to see your specialist for a
certain number of visits without additional referrals Your primary care physician will use our criteria
when creating your treatment plan

What do I do if I am Your primary care physician will decide what treatment you need If they decide to refer you to a seeing a specialist specialist ask if you can see your current specialist If your current specialist does not participate with

when I enroll us you must receive treatment from a specialist who does Generally we will not pay for you to see a specialist who does not participate with our Plan For Whatcom and Skagit Division or Central and
Eastern Washington and Northern Idaho members only if the doctor who originally referred you to this
specialist is now your Plan primary care doctor you need only call to explain that you are now a Plan
member and ask that you be referred for your next appointment

What do I do if my Call your primary care physician who will arrange for you to see another specialist You may receive specialist leaves the Plan services from your current specialist until we can make arrangements for you to see someone else

8 8
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GROUP HEALTH COOPERATIVE 2000
Section 3 How to get benefits continued
But what if I have a serious Please contact us if you believe your condition is chronic or disabling You may be able to continue illness and my provider seeing your provider for up to 90 days after we notify you that we are terminating our contract with the
leaves the Plan or this Plan provider unless the termination is for cause If you are in the second or third trimester of pregnancy leaves the Program you may continue to see your OB GYN until the end of your postpartum care

You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and
you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic
condition or are in your second or third trimester Your new plan will pay for or provide your care for up
to 90 days after you receive notice that your prior plan is leaving the FEHB Program If you are in your
second or third trimester your new plan will pay for the OB GYN care you receive from your current
provider until the end of your postpartum care

How do you authorize Your physician must get our approval before sending you to a hospital referring you to a specialist or medical services recommending follow up care Before giving approval we consider if the service is medically necessary

and if it follows generally accepted medical practice
How do you decide if a The Plan makes its determination of experimental or investigational treatment including medical and service is experimental surgical services drugs devices and biological products upon review of evidence provided by

or investigational evaluations of national medical associations consensus panels and or other technological evaluations including the scientific quality of such supporting evidence and rationale The information it reviews
comes from the U S Food and Drug Administration and from scientific evidence in published medical
literature as well as in published peer reviewed medical literature

Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were
unable to make a timely request due to reasons beyond your control

We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information

If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30 days
after we receive the additional information If we do not receive the requested information within 60 days we will make our decision
based on the information we already have

When may I ask OPM You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal OPM to review a denial will determine if we correctly applied the terms of our contract when we denied your claim or request
for service
What if I have a serious or Call us at 888 901 4636 and we will expedite our review life threatening condition

and you haven't responded to my request for service

What if you have denied If we expedite your review due to a serious medical condition and deny your claim we will inform OPM my request for care and so that they can give your claim expedited treatment too Alternatively you can call OPM's Health
my condition is serious Benefits Contracts Division 3 at 202 606 0755 between 8 a m and 5 p m Serious or life threatening 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
9 9
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GROUP HEALTH COOPERATIVE 2000
Section 4 What to do if we deny your claim or request for service continued
Are there other time limits You must write to OPM and ask them to review our decision within 90 days after we uphold our initial denial or refusal of service 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 OPM Your request must be complete or OPM will return it to you You must send the following information
1 A statement about why you believe our decision is wrong based on specific benefit provisions in
this brochure

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

3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call

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

Who can make the request Those who have a legal right to file a disputed claim with OPM are
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 3 P O Box 436 Washington D C 20044

What if OPM upholds OPM's decision is final There are no other administrative appeals If OPM agrees with our decision the Plan's denial 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 its a lawsuit review on the record that was before OPM when OPM made its decision on your claim You may

recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment
services supplies or drugs covered by us until you have completed the OPM review procedure described
above

Your records and the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and us Privacy Act to determine if our denial of your claim is correct The information OPM collects during the review

process becomes a permanent part of your disputed claims file and is subject to the provisions of the
Freedom of Information Act and the Privacy Act OPM may disclose this information to support the
disputed claim decision If you file a lawsuit this information will become part of the court record

10 10
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GROUP HEALTH COOPERATIVE 2000
Section 5 Benefits
Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits you pay a 10 office visit copay but no
additional copay for laboratory tests and X rays Within the service area house calls will be provided if
in the judgment of the Plan doctor such care is necessary and appropriate you pay nothing for a doctor's
house call and nothing for home visits by nurses and health aides

The following services are included and are subject to the office visit copay unless stated otherwise
Preventive care including periodic check ups according to well care schedule and well baby care
copay is waived

Mammograms are covered as follows for women age 35 through age 39 one mammogram during
these five years for women age 40 through 49 one mammogram every one or two years for women
age 50 through 64 one mammogram every year and for women age 65 and above one mammogram
every two years In addition to routine screening mammograms are covered when prescribed by the
doctor as medically necessary to diagnose or treat your illness

Routine immunizations and boosters copay is waived
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal
care by a Plan doctor Copays are waived for maternity care The mother at her option may
remain in the hospital up to 48 hours after a regular delivery and 96 hours after a caesarean delivery
If enrollment in the Plan is terminated during pregnancy benefits will not be provided after coverage
under the Plan has ended Ordinary nursery care of the newborn child during the covered portion of
the mother's hospital confinement for maternity will be covered under either a Self Only or Self and
Family enrollment other care of an infant who requires definitive treatment will be covered only if
the infant is covered under a Self and Family enrollment

Voluntary sterilization therapeutic and nontherapeutic procedures and family planning counseling
services

Diagnosis and treatment of diseases of the eye
Blood derivatives and the administration of blood
Allergy testing and treatment including testing and treatment materials
The insertion of internal prosthetic devices such as pacemakers artifical joints intraocular lenses
cochlear implants and penile implants excluded from coverage are the costs of a penile implanted
device and artificial or mechanical hearts

Cornea heart heart lung kidney liver lung single or double and pancreas kidney transplants allogeneic
donor bone marrow transplants autologous bone marrow transplants autologous stem cell
and peripheral stem cell support for the following conditions acute lymphocytic or non lymphocytic
leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma advanced neuroblastoma
breast cancer multiple myeloma epithelial ovarian cancer and testicular mediastinal retroperitoneal
and ovarian germ cell tumors Related medical and hospital expenses of the donor are
covered when the recipient is covered by this Plan and are limited to procurement center fees travel
costs for a surgical team excision fees and matching tests Transportation and living expenses are
excluded

Women who undergo mastectomies may at their option have this procedure performed on an inpatient
basis and remain in the hospital up to 48 hours after the procedure

Dialysis
Chemotherapy radiation therapy and inhalation therapy

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
11 11
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GROUP HEALTH COOPERATIVE 2000
Section 5 Benefits continued
Surgical treatment of morbid obesity
Home health services of nurses and health aides including intravenous fluids and medications when
prescribed by your Plan doctor who will periodically review the program for continuing appropriateness
and need

All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and
other Plan providers at no additional cost to you

Routine nutritional counseling
Total parenteral nutritional therapy and supplies necessary for its administration you pay nothing
Enteral nutritional therapy when necessary due to malabsorption including equipment and supplies
you pay 20 of charges for enteral nutrition therapy and nothing for equipment and supplies Over
the counter formulas are excluded

Dietary formula for the treatment of Phenylketonuria PKU
Routine circumcision
Diabetic training and education

Limited benefits
Oral and is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip maxillofacial surgery and cleft palate and for medical or surgical procedures occurring within or adjacent to the oral cavity or
sinuses including but not limited to treatment of fractures and excision of tumors and cysts Treatment
of temporomandibular joint TMJ pain dysfunction syndrome is covered you pay 50 of charges All
other procedures involving the teeth or intra oral areas surrounding the teeth are not covered including
any dental care involved in the treatment of TMJ pain dysfunction syndrome

Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from an injury or surgery that has produced a major effect on the member's appearance and if the condition can reasonably be

expected to be corrected by such surgery A patient and her attending physician may decide whether to
have breast reconstruction surgery following a mastectomy and whether surgery on the other breast is
needed to produce a symmetrical appearance Following mastectomy internal breast prostheses are
covered you pay nothing

Short term physical occupational speech and massage is provided on an inpatient and outpatient basis to restore rehabilitative therapy function following illness injury or surgery Coverage is limited to two months per condition per

calendar year for combined inpatient services and 60 visits per condition per calendar year for combined
outpatient services You pay a 10 copay per outpatient session Services are limited to those
necessary to restore or improve functional abilities when impairment exists due to injury or illness and
those for which significant improvement can be expected within two months as a consequence of intervention
by therapy services Subject to the above limits services for the restoration and improvement of
function for neurodevelopmentally disabled children age six 6 and under are covered including maintenance
in cases where significant deterioration of the child's condition would result without such services

Diagnosis and treatment is covered For nonexperimental infertility services that are limited to general diagnostic services you of infertility pay a 10 copay per outpatient visit For specific diagnostic services medical and surgical treatment
including the following types of artificial insemination intravaginal insemination IVI intracervical
insemination ICI and intrauterine insemination IUI you pay 50 of charges Donor expenses for
infertility treatment including donor sperm are not covered Fertility drugs are not covered Other
assisted reproductive technology ART procedures such as in vitro fertilization and embryo transfer
are not covered

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
12 12
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GROUP HEALTH COOPERATIVE 2000
Section 5 Benefits continued
Chiropractic services without a referral for manipulative therapy of the spine and extremities are covered when provided by Plan providers The medical necessity for manipulative therapy must meet Plan protocol Excluded
from coverage are services not listed in the Plan's protocol including but not limited to supportive care
provided primarily to maintain the level of correction already achieved care given primarily for the
convenience of the member care given on a non acute asymptomatic basis or charges for office visits
other than the initial evaluation You pay a 10 copay per visit

Podiatric services which meet Plan protocol and are authorized in advance by the member's primary care doctor excluded is treatment of flat feet or other misalignments of the feet removal of corns and calluses and hygienic

foot care except in the presence of a non related medical condition affecting the lower limbs You pay
a 10 copay per visit

Naturopathic services which meet Plan protocol and are authorized in advance by the member's primary care doctor excluded are botanical herbal medicines vitamins and food supplements You pay a 10 copay per visit

Acupuncture services which meet Plan protocol and are authorized in advance by the member's primary care doctor excluded are botanical and herbal medicines You pay a 10 copay per visit
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction when provided at a Plan facility you pay a 10 copay per visit
Durable medical equipment such as hospital beds wheelchairs walkers crutches canes oxygen and oxygen equipment for home use nasal CPAP device glucose monitors and external insulin pumps as well as medically necessary
replacement of supplies are covered subject to the rental price or purchase price if the cost of purchase
is less than the anticipated total rental charges as determined solely by the Plan you pay 20 of
charges Replacement of devices equipment and supplies due to loss breakage or damage is excluded

Prosthetic devices such as artificial limbs ostomy supplies necessary for the removal of bodily secretions or waste through an artificial opening external breast prostheses following a mastectomy and post mastectomy bras as

well as medically necessary replacement of devices are covered you pay 20 of charges Replacement
of devices equipment and supplies due to loss breakage or damage is excluded

Orthopedic appliances such as braces are covered occlusal splints including fittings are the only devices covered for treatment of temporomandibular joint TMJ dysfunction therapeutic shoe inserts are covered only for

severe diabetic foot disease as well as medically necessary replacement of appliances are covered you
pay 20 of charges Corrective shoes and over the counter custom shoe inserts and their fittings are
excluded as are replacement of devices equipment and supplies due to loss breakage or damage

What is not covered Physicial examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance attending school or camp or travel

Reversal of therapeutic or nontherapeutic sterility
Surgery primarily for cosmetic purposes
Homemaker services
Hearing Aids
Transplants not listed as covered
Long term rehabilitative therapy
Foot orthotics
The cost of blood
Any eye surgery solely for the purpose of correcting refractive defects of the eye such as nearsightedness
myopia farsightedness hyperopia and astigmatism blurring

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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GROUP HEALTH COOPERATIVE 2000
Hospital Extended Care Benefits
What is covered
Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan doctor You pay nothing All necessary services are covered including

Semiprivate room accommodations when a Plan doctor determines it is medically necessary the
doctor may prescribe private accommodations or private duty nursing care

Specialized care units such as intensive care or cardiac care units

Extended care The Plan provides a comprehensive range of benefits for up to 30 days per calendar year with no dollar limit when full time skilled nursing care is necessary and confinement in a skilled nursing facility is

medically appropriate as determined by a Plan doctor and approved by the Plan You pay nothing All
necessary services are covered including

Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing
facility when prescribed by a Plan doctor

Hospice care Supportive and palliative care for a terminally ill member is covered in the home or a hospice facility Services could include inpatient and outpatient care drugs biologicals medical appliances and supplies

that are used primarily for the relief of pain and symptom management and family counseling
these services are provided under the direction of a Plan doctor who certifies that the patient is in the
terminal stages of illness with a life expectancy of approximately six months or less

Ambulance service Benefits are provided for ground and air ambulance transportation to a Plan facility Plan designated facility or non Plan designated facility ordered or authorized by a Plan doctor You pay 20 of charges

Limited benefits
Inpatient dental procedures Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need for hospitalization for a medical condition totally unrelated to the dental procedure the Plan will cover

the hospitalization but not the cost of the professional dental services Conditions for which hospitalization
would be covered include hemophilia and heart disease the need for anesthesia by itself is not
such a condition

Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis detoxification treatment of medical conditions and medical management of withdrawal symptoms acute detoxification

if the Plan doctor determines that outpatient management is not medically appropriate See page
14 for nonmedical substance abuse benefits

What is not covered Personal comfort items such as telephone and television
Blood not replaced by the member
Custodial care rest cures domiciliary or convalescent care

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe emergency endangers your life or could result in serious injury or disability and requires immediate medical or
surgical care Some problems are emergencies because if not treated promptly they might become
more serious examples include deep cuts and broken bones Others are emergencies because they are
potentially life threatening such as heart attacks strokes poisonings gunshot wounds or sudden inability
to breathe There are many other acute conditions that the Plan may determine are medical
emergencies what they all have in common is the need for quick action

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GROUP HEALTH COOPERATIVE 2000
Emergency Benefits continued
Emergencies within the If you are in an emergency situation please call your primary care doctor In extreme emergencies if service area you are unable to contact your doctor contact the local emergency system e g the 911 telephone
system or go to the nearest hospital emergency room It is your responsibility to ensure that the Plan
has been timely notified

If you need to be hospitalized in a non Plan facility the Plan must be notified within 24 hours by calling
the Plan notification line at 888 457 9516 unless it was not reasonably possible to notify the Plan
within that time If you are hospitalized in non Plan facilities and a Plan doctor believes care can be
better provided in a Plan hospital you will be transferred when medically feasible with any ambulance
charges covered in full If you have questions about acute illness other than emergencies you should
call your primary care doctor

Benefits are available for care from non Plan providers in a medical emergency only if delay in reaching
a Plan provider would result in death disability or significant jeopardy to your condition

To be covered by this Plan any follow up care recommended by non Plan providers must be approved
by the Plan or provided by Plan providers

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

You pay At a facility not designated by the Plan you pay a deductible of 100 per member per visit At a Plan hospital or Plan designated emergency facility you pay a 50 copay per member per visit If more than
one covered member of an enrollee's immediate family requires emergency care as result of the same
accident only one emergency copay or deductible will apply If you are admitted to an in Plan hospital
or designated facility directly from the emergency room the in Plan copayment is waived

Emergencies outside Benefits are available for any medically necessary health service that is immediately required because the service area of injury or unforeseen illness

If you need to be hospitalized the Plan must be notified within 24 hours or on the first working day
following your admission unless it was not reasonably possible to notify the Plan within that time If a
Plan doctor believes care can be better provided in a Plan hospital you will be transferred when medically
feasible with any ambulance charges covered in full

To be covered by this Plan any follow up care recommended by non Plan providers must be approved
by the Plan or provided by Plan providers

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

You pay Same as within the service area
What is covered Emergency care at a doctor's office or an urgent care center
Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance ground and air service approved by the Plan you pay 20 of charges

What is not covered Elective care or nonemergency care
Emergency care provided outside the service area if the need for care could have been foreseen before
leaving the service area

Follow up care that is not approved by the Plan

Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency care non Plan providers upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form If

you are required to pay for the services submit itemized bills and your receipts to the Plan along with an
explanation of the services and the identification information from your ID card

Payment will be sent to you or the provider if you did not pay the bill unless the claim is denied If it
is denied you will receive notice of the decision including the reasons for the denial and the provisions
of the contract on which denial was based If you disagree with the Plan's decision you may request
reconsideration in accordance with the disputed claims procedure described on page 7

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GROUP HEALTH COOPERATIVE 2000
Mental Conditions Substance Abuse Benefits
Mental conditions
What is covered To the extent shown below the Plan provides the following medically necessary services as determined by the Plan providers for the diagnosis and treatment of acute psychiatric conditions including the

treatment of mental illness or disorders limited to
Diagnosis evaluation and consultation services
Psychological testing as part of the treatment program
Psychiatric medical services including medical management including individual family and group
therapy and medications see Prescription Drug Benefits

Hospitalization including inpatient professional services

Outpatient care All necessary outpatient visits to Plan providers each calendar year you pay nothing for the first 20 visits a 15.70 copay per visit thereafter

Inpatient care Up to 30 days of hospitalization each calendar year you pay 20 of charges for the first 30 days all charges thereafter The member's 20 copay applies to the out of pocket maximum of 1,000 per Self
Only enrollment or 2,000 per Self and Family enrollment
What is not covered Care for psychiatric conditions for which in the professional judgement of Plan providers improvement or stabilization is not expected to occur

Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless determined
by a Plan doctor to be necessary and appropriate

Psychological testing that is not medically necessary to determine the appropriate treatment of a
short term psychiatric condition

Substance abuse
What is covered The Plan provides medical and hospital services such as acute detoxification services for the medical non psychiatric aspects of substance abuse including alcoholism and drug addiction the same as for

any other illness or condition and to the extent shown below the services necessary for diagnosis and
treatment

Outpatient care All necessary outpatient substance abuse visits are covered You pay nothing
Inpatient care Covered under Mental conditions benefit
What is not covered Treatment that is not authorized by a Plan doctor
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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GROUP HEALTH COOPERATIVE 2000
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 30 day supply You pay a 7 copay per prescription unit or refill for up to a 30 day
supply or 100 unit supply whichever is less or one commercially prepared unit i e one inhaler one
vial ophthalmic medication or insulin

You pay a 7 copay per prescription unit or refill for generic drugs or for name brand drugs when
generic substitution is not permissible When generic substitution is permissible i e a generic drug is
available and the prescribing doctor does not require the use of a name brand drug but you request the
name brand drug you pay the price difference between the generic and name brand drug as well as the
7 copay per prescription unit or refill

Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary
Nonformulary drugs will be covered when prescribed by a Plan doctor

Covered medications and accessories include
Drugs including injectables for which a prescription is required by Federal law
Insulin
Diabetic supplies including needles syringes lancets urine and blood glucose testing reagents and
visual strips a copay charge applies per item per each 30 day supply

Contraceptive drugs and devices for Norplant device you pay a 140 copay
Compound dermatological preparations
Disposable needles and syringes needed to inject covered prescribed medication
Allergy serum
Injectable contraceptive drugs
Intravenous fluids and medication for home use implantable drugs and some injectable drugs are
covered under Medical and Surgical Benefits

Limited benefits Drugs to aid in tobacco cessation Participation in the Plan's Free and Clear Program is required in order to receive coverage for one course of nicotine replacement therapy per calendar year subject to

the 7 pharmacy copay
Sexual dysfunction drugs are subject to a 50 copay and dosage limits set by the Plan Contact the
Plan for details

What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available
Drugs obtained at a non Plan pharmacy
Vitamins and nutritional substances including dietary formulas and special diets except for the treatment
of phenylketonuria PKU total parenteral and enteral nutrition therapy

Medical supplies such as dressings antiseptics etc
Experimental drugs devices and biological products
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Fertility drugs

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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GROUP HEALTH COOPERATIVE 2000
Other Benefits
Dental care IMPORTANT The following is a summary of the Plan's dental benefits Please call the Plan's Member Services Department at 206 448 4140 or 800 542 6312 for more information on additional

exclusions and limitations
What is covered This dental program will pay a percentage of the reasonable and customary charge for dental services listed below and will reimburse any dentist dental hygienist under the supervision of a dentist or

denturist that you select YOU ARE NOT REQUIRED TO RECEIVE YOUR CARE FROM SPECIFIED
DENTAL PROVIDERS You pay an annual deductible of 50 per member and 150 per family
per year up to 1,000 maximum benefit per member per year as well as any amounts over Plan payment
Important Benefits are provided only for services included in the list of covered dental
services and no charges will be paid in excess of the reasonable and customary charge No dental
benefit will be paid for any dental service or supply which is incomplete or temporary

Covered preventive dental expenses are paid at 100 of the reasonable and customary charge you
pay nothing

Prophylaxis cleaning and polishing of teeth not more than once in any five month period
Routine oral examinations except for orthodontics
Fluoride treatment for children under age 16
Dental X rays except for orthodontics
Bacteriologic cultures and biopsies of tissue
Emergency palliative treatment for relief of dental pain
Space maintainers except for orthodontics
Covered basic dental expenses are paid at 50 of the reasonable and customary charge you pay 50
of the charges

Endodontic treatment as follows root canal therapy pulpotomy apicoectomy and retrograde fillings
Simple extractions
Oral surgery
Basic periodontal services limited to occlusal adjustment when performed with a covered root scaling
Study models
Crown build up on non vital teeth
Pin retention of fillings
Fillings restorations using amalgam silicate acrylic synthetic porcelain and composite fill materials
to restore teeth broken down by decay or injury on posterior teeth an allowance will only be
made for an amalgam filling

Recementing inlays onlays and crowns
Recementing bridges
Repairs to full and partial dentures and bridges
General anesthetics and analgesics
Injectable antibiotics
Covered major dental expenses are paid at 30 of the reasonable and customary charge you pay
70 of charges

Major periodontal treatment of the gums and supporting structure of the teeth
Bridges and dentures
Crowns and gold restorations
Replacement of damaged appliances

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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GROUP HEALTH COOPERATIVE 2000
Other Benefits continued
What is not covered Other dental services not shown as covered
Vision care
What is covered In addition to the medical and surgical benefits provided for the diagnosis and treatment of diseases of the eye the Plan provides certain vision care benefits from Plan providers

Routine eye examinations and refractions including eyeglass lens prescription limited to once every
12 months except when medically necessary You pay a 10 copay per visit

When dispensed through Plan facilities one contact lens per diseased eye including exam and fitting
for members following cataract surgery performed by a Plan doctor in lieu of an intraocular
lens Replacement of covered contact lenses will be provided only when needed due to change in the
member's medical condition and will be replaced only one time within any 12 month period

What is not covered Eyeglasses
Contact lenses and related supplies including examination and fitting except as provided above
Orthoptic eye training

Benefits available away If you are traveling and are outside the Plan's service area by more than 100 miles certain health from home services i e follow up care and continuing care are covered You pay a 25 copay per follow up or

continuing care visit up to a maximum Plan copayment of 1,200 per person per calendar year You
must pay the provider at the time you receive the services and if the services are covered under this
benefit you will be reimbursed the reasonable charges for the care up to a maximum of 1,200 per
person per calendar year and the 25 copay per visit will be deducted from the payment you receive
from the Plan

Submit a claim to the Plan for the services on a HCFA Form 1500 with necessary supporting documentation
i e itemized bills and receipts along with an explanation of the services and the identification
information from your ID card Send the claims to Group Health Cooperative Claims Administration
PO Box 34585 Seattle WA 98124 1585

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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GROUP HEALTH COOPERATIVE 2000
Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made
available to all enrollees and family members of this Plan The cost of the benefits described on this page is not included in the FEHB
premium and any charges for these services do not count toward any FEHB deductibles or out of pocket maximums These benefits
are not subject to the FEHB disputed claims procedure

Group Health Cooperative Resource Line The Group Health Resource Line is a free information and referral service available to all GHC consumers Volunteer staff
provides up to date information about health education community resources and senior services The Line includes information
on a wide variety of health promotion and disease oriented topics It also includes information about Take Care store products
classes within GHC support groups and pamphlets This service is available by calling 206 326 2800 or 1 800 992 2279 outside the
Seattle dialing areas

Seniors The Resource Line specializes in information for seniors including listings on home care transportation and other
resources in your community In addition pamphlets are available on coping with stress and depression routine foot care medication
tips and sleeping better

Health promotion The Group Health Resource Line has pamphlets to help you learn how to reduce fat in your diet manage
stress and keep track of your medications Call and ask for the Fats of Life packet Managing Everyday Stress workbook or the
Medication Record wallet card

Group Health Cooperative Health Promotion Programs The Free and Clear Program Group Health's tobacco cessation program is offered as an individual phone based program or as
a group program with classes Free Clear is a medically proven program shown to double your chances of successful quitting
Participants receive a Free Clear kit with program and support materials Individual program participants receive five phone calls
from a tobacco cessation specialist Group participants attend eight classes taught by a qualified instructor Call the Center for
Health Promotion today for more information to register for the Free Clear program or to request a program brochure 206 287
2527 or 1 800 462 5327 outside the Seattle dialing area

Advance Directive Program Public programs are available throughout the area to educate people about Living Wills Durable
Power of Attorney for Healthcare and other advance directives Group Health and Senior Rights Assistance schedule volunteers who
work individually with people to explain how to use these documents For more information or to request a copy of advance
directives call the Group Health Resource Line

Senior Caucus All Group Health enrollees who are seniors are invited to chapter meetings for interesting programs on health
promotion topics such as self care exercise humor and chronic conditions To receive a mailed announcement of the location time
and topic of the chapter nearest you call the Group Health Resource Line

Medicare Choice prepaid plan enrollment This Plan offers Medicare recipients the opportunity to enroll in the Plan through
Medicare As indicated on page 19 annuitants and former spouses with FEHB coverage and Medicare Part B may elect to drop their
FEHB coverage and enroll in a Medicare Choice prepaid plan when one is available in their area They may then later reenroll in the
FEHB Program Most Federal annuitants have Medicare Part A Those without Medicare Part A may join this Medicare Choice
prepaid plan but will probably have to pay for hospital coverage in addition to the Part B premium Before you join the plan ask
whether the plan covers hospital benefits and if so what you will have to pay Contact your retirement system for information on
dropping your FEHB enrollment and changing to a Medicare Choice prepaid plan Contact us at 206 901 4600 or toll free at 1 888
901 4600 for information on the Medicare Choice prepaid plan and the cost of that enrollment

If you are Medicare eligible and are interested in enrolling in a Medicare HMO sponsored by this Plan without dropping your
enrollment in this Plan's FEHB plan call 206 901 4600 or toll free at 1 888 901 4600 for information on the benefits available under
the Medicare HMO

Benefits on this page are not part of the FEHB contract

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GROUP HEALTH COOPERATIVE 2000
Section 6 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
your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition

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
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus
were carried to term or when the pregnancy is the result of an act of rape or incest

Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan

Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On occasion you may
need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled
with us

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

If you involuntarily lose coverage or move out of the Medicare Choice service area you may re enroll
in the FEHB Program at any time

If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your
benefits will not be reduced We cannot require you to enroll in Medicare

For information on Medicare Choice plans contact your local Social Security Administration SSA
office or request it from SSA at 1 800 638 6833 For information on the Medicare Choice plan offered
by this Plan see page 18

Other group When anyone has coverage with us and with another group health plan it is called double coverage You insurance coverage 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 what the reasonable charge for the benefit should be After the first
plan pays we will pay either what is left of the reasonable charge or our regular benefit whichever is
less We will not pay more than the reasonable charge If we are the secondary payer we may be
entitled to receive payment from your primary plan

We will always provide you with the benefits described in this brochure Remember even if you do not
file a claim with your other plan you must still tell us that you have double coverage

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GROUP HEALTH COOPERATIVE 2000
Section 7 Limitations Rules that affect your benefits continued
Circumstances beyond Under certain extraordinary circumstances we may have to delay your services or be unable to provide our control them In that case we will make all reasonable efforts to provide you with necessary care

When others are When you receive money to compensate you for medical or hospital care for injuries or illness that responsible for injuries another person caused you must reimburse us for whatever services we paid for We will cover the cost
of treatment that exceeds the amount you received in the settlement If you do not seek damages you
must agree to let us try This is called subrogation If you need more information contact us for our
subrogation procedures

TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you we are the

primary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE
coverage

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

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

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

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

Section 8 FEHB FACTS
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right to information about information about your health plan its networks providers and facilities You can also find out about
your HMO care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's website www opm gov lists
the specific types of information that we must make available to you
If you want specific information about us call 888 901 4636 or write to Group Health Cooperative at
PO Box 34590 Seattle WA 98124 1590 You may also contact us by fax at 206 901 4612 or visit our
website at http www ghc org or http www ghnw org or by e mail at info ghc org

Where do I get information Your employing or retirement office can answer your questions and give you a Guide to Federal about enrolling in the Employees Health Benefits Plans brochures for other plans and other materials you need to make an

FEHB Program informed decision about
When you may change your enrollment
How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter military
service or retire

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

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GROUP HEALTH COOPERATIVE 2000
Section 8 FEHB FACTS continued
When are my benefits The benefits in this brochure are effective on January 1 If you are new to this plan your coverage and and premiums effective 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 When you retire you can usually stay in the FEHB Program Generally you must have been enrolled in I retire the FEHB Program for the last five years of your Federal service If you do not meet this requirement

you may be eligible for other forms of coverage such as Temporary Continuation of Coverage which is
described later in this section

What types of coverage Self Only coverage is for you alone Self and Family coverage is for you your spouse and your are available for my unmarried dependent children under age 22 including any foster or step children your employing or

family and me retirement office authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years of age or older who is incapable of self support

If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry give birth
or add a child to your family You may change your enrollment 31 days before to 60 days after you give birth
or add the child to your family The benefits and premiums for your Self and Family enrollment begin on the
first day of the pay period in which the child is born or becomes an eligible family member

Your employing or retirement office will not notify you when a family member is no longer eligible to
receive health benefits nor will we Please tell us immediately when you add or remove family members
from your coverage for any reason including divorce

If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled in
another FEHB plan

Are my medical and claims We will keep your medical and claims information confidential Only the following will have access records confidential to it

OPM this Plan and 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 subrogating claims

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

Information for new members
Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF2809 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 enroll You will receive an additional 31 days of coverage for no additional premium when ment in this Plan ends

Your enrollment ends unless you cancel your enrollment or
You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage
23 23
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GROUP HEALTH COOPERATIVE 2000
Section 8 FEHB FACTS continued
What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits under spouse coverage your former spouse's enrollment But you may be eligible for your own FEHB coverage under the
spouse equity law If you are recently divorced or are anticipating a divorce contact your ex spouse's
employing or retirement office to get more information about your coverage choices

What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For example you can

receive TCC if you are not able to continue your FEHB enrollment after you retire You may not elect
TCC if you are fired from your Federal job due to gross misconduct

Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health
Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your employing
or retirement office

Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from
the 32 nd day after your regular coverage ends even if several months have passed

You pay the total premium and generally a 2 percent administrative charge The government does
not share your costs

You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel
your TCC or stop paying the premium

You are not eligible for TCC if you can receive regular FEHB Program benefits

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

Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify your
employing or retirement office within the 60 day deadline

How can I convert to You may convert to an individual policy if individual coverage

Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not pay
your premium you cannot convert

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

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GROUP HEALTH COOPERATIVE 2000
Section 8 FEHB FACTS continued
If you leave Federal service your employing office will notify you if individual coverage is available
You must apply in writing to us within 31 days after you receive this notice However if you are a
family member who is losing coverage the employing or retirement office will not notify you You
must apply in writing to us within 31 days after you are no longer eligible for coverage

Your benefits and rates will differ from those under the FEHB Program however you will not have to
answer questions about your health and we will not impose a waiting period or limit your coverage due
to pre existing conditions

How can I get a Certificate If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that of Group Health indicates how long you have been enrolled with us You can use this certificate when getting health

Plan Coverage insurance or other health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions for
health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in other FEHB
plans you may request a certificate from them as well

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 206 448 4140 or 800 542 6312 and explain the situation
If we do not resolve the issue call or write
THE HEALTH CARE FRAUD HOTLINE
202 418 3300

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

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

Try to obtain services for a person who is not an eligible family member or
Are no longer enrolled in the Plan and try to obtain benefits
Your agency may also take administrative action against you

25 25
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GROUP HEALTH COOPERATIVE 2000
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GROUP HEALTH COOPERATIVE 2000
Summary of Benefits for Group Health Cooperative 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set
forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or change your
enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of this
brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY CARE ARE COVERED
ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS

Benefits Plan pays provides Page
Inpatient care Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes in hospital doctor care room and board general

nursing care private room and private nursing care if medically necessary
diagnostic tests drugs and medical supplies use of operating room
intensive care and complete maternity care You pay nothing 12

Extended care All necessary services for up to 30 days You pay nothing 12
Mental conditions Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per year You pay 20 of charges 14

Substance abuse Covered under Mental conditions 14
Outpatient care Comprehensive range of services such as diagnosis and treatment of illness or injury including specialist's care laboratory tests and X rays

complete maternity care You pay a 10 copay per office visit nothing
per house call by a doctor nothing for preventive care including
well baby care periodic check ups and routine immunizations and
nothing for maternity care 9

Home health care All necessary visits by nurses and health aides You pay nothing 10

Mental conditions All necessary outpatient visits per year You pay nothing for visits 1 20 a 15.70 copay thereafter 14

Substance abuse All necessary visits You pay nothing 14
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 100 deductible for each emergency

visit to a non Plan facility a 50 copay at a Plan facility and any
charges for services that are not covered by this Plan 12 13

Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 7 copay per prescription unit or refill 15

Dental care Preventive dental care wide range of restorative and other services Comprehensive range of services You pay a 50 annual deductible
per member 150 per family variable copays for most care
and any charges beyond the Plan payment 16 17

Vision care Routine eye exam and refractions for eyeglasses You pay a 10 copay per outpatient visit 17

Out of pocket maximum Copayments are required for a few benefits however after your out of pocket expenses reach a maximum of 1,000 per Self Only
or 2,000 per Self and Family enrollment per calendar year
covered benefits will be provided at 100 This copay maximum
does not include charges for infertility treatment services devices
equipment and supplies dental care the 100 non Plan emergency
care deductible the 20 coinsurance for ambulance services and
the outpatient mental health care copayment 5

27 27
27 Page 28
2000 Rate Information for
Group Health Cooperative of Puget Sound

Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the FEHB Guide for that
category or contact the agency that maintains your health benefits enrollment

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

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

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

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

Western Washington
Self Only 541 78.83 28.50 170.80 61.75 93.06 14.27 93.26 14.07
Self and Family 542 175.97 66.19 381.27 143.41 207.74 34.42 201.02 41.14

Eastern Central Washington and Northern Idaho
Self Only VR1 78.83 30.33 170.80 65.71 93.06 16.10 93.26 15.90
Self and Family VR2 175.97 105.23 381.27 228.00 207.74 73.46 201.02 80.18 28

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