Health Alliance Plan 2000
A Health Maintenance Organization
For changes in benefits
page
3
see
Serving Detroit and Southeastern Michigan
Enrollment in this Plan is limited see page 4 for
requirements
Enrollment code
521 Self Only
522 Self and Family
The National Committee for Quality Assurance
awarded its highest accreditation status of Excellent to
the HAP Commercial HMO for service and clinical
quality that meets or exceeds NCQA rigorous
requirements for consumer protection and quality
improvement See the 2000 FEHB Guide for more
information on NCQA
Visit the OPM website at httpwwwopmgovinsure
and
this Plans web page at httpwwwhapcorporg
Authorized for distribution by the
United States Office of
Personnel Management
Retirement and Insurance Service RI 73 015
1
1
Page 2
3
HEALTH ALLIANCE PLAN 2000
Table of Contents
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
Section 3 How to get benefits
4
Section 4 What to do if we deny your claim or request for service
7
Section 5 Benefits
9
NonFEHB Benefits
17
Section 6 General exclusions Things we dont cover
18
Section 7 Limitations Rules that affect your benefits
19
Section 8 FEHB FACTS
21
Inspector General Advisory Stop Health Care Fraud
24
Summary of benefits
Inside Back Cover
Premiums
Back Cover
2
2
Page 3
4
HEALTH ALLIANCE PLAN 2000
Introduction
Health Alliance Plan 2850 W Grand Blvd Detroit MI 48202
This brochure describes the benefits you can receive from Health Alliance Plan under its contract CS1092 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
page 3 Premiums are listed at the end of this brochure
Plain language
The President and Vice President are making the Governments 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 Health Alliance Plan 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 rewritten the Benefits section of this brochure You will find new benefits language next year
1
3
3
Page 4
5
HEALTH ALLIANCE PLAN 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 Plans benefits
with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make compari
sons 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 informa
tion about nonFEHB benefits
6 General exclusions Things we dont 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
2
4
4
Page 5
6
HEALTH ALLIANCE PLAN 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 preventive
care such as routine office visits physical exams wellbaby 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 Plans 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
andor remain under contract with us Our providers follow generally accepted medical practices when prescribing any course of
treatment
Section 2 How we change for 2000
Programwide To keep your premium as low as possible OPM has set a minimum copay of 10 for all
Changes 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 OBGYN
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 NonPostal premium will increase by 99 for Self Only or 99 for Self and Family
Plan provider office visit copay increased from 5 to 10 See page 3 9 10 16
The Plan service area expanded to three 3 new counties They are Lapeer Livingston and
Monroe See Page 4 for details
3
5
5
Page 6
7
HEALTH ALLIANCE PLAN 2000
Section 3 How to get benefits
What is this Plans To enroll with us you must live or work in our service area This is where our providers practice
service area Our service area includes Genessee Lapeer Livingston Macomb Monroe Oakland St Clair Washtenaw and Wayne counties
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 care We will not pay for any other
health care services outside of the service area
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 feeforservice 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
How much do I You must share the cost of some services This is called either a copayment a set dollar amount
pay for services or coinsurance a set percentage of charges Please remember you must pay this amount when you receive services except for emergency services
Your outofpocket expenses for benefits covered under this Plan are limited to the stated
copayments which are required for a few benefits
Do I have to You normally wont have to submit claims to us unless you receive emergency services from a
submit claims provider who doesnt 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 circum
stances beyond your control prevented you from filing on time
Who provides my Health Alliance Plan is a mixed model prepayment plan that provides medical services at conve
health care niently located medical centers staffed by more than 600 doctors and from more than 1500 additional private doctors working from their individual office locations
The most important decision each member must make is the selection of a Plan 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 Plan 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 you have been referred by your
Plan doctor The only exception is that women may see their participating provider of obstetric
and gynecological of record directly with no need to be referred by their Plan doctor
The Plans provider directory lists Plan doctors with their locations and phone numbers Directo
ries are updated on a regular basis and are available at the time of enrollment If you have a
question concerning Plan benefits or how to arrange for care contact the Plans Member Services
Office at 313 8728100 or 18004224641 or you may write to the Plan at 2850 W Grand
Blvd Detroit MI 48202 You may also contact the plan by fax at 313 6648400 or at its website
at wwwhapcorporg
Important note When you enroll in this Plan services except for emergency benefits are
provided through the Plans delivery system the continued availability andor participation of any
one doctor hospital or other provider cannot be guaranteed
What do I do if my Call us We will help you select a new one
Plan physician leaves
the Plan
4
6
6
Page 7
8
HEALTH ALLIANCE PLAN 2000
Section 3 How to get benefits continued
What do I do if I Talk to your Plan physician If you need to be hospitalized your Plan physician or specialist will
need to go into the make the necessary hospital arrangements and supervise your care Outpatient surgery may be
hospital performed at affiliated hospitals or outpatient surgery centers
What do I do if Im First call our Member Services Department at 313 8728100 or 18004224641 If you are new
in the hospital when I to the FEHB Program we will arrange for you to receive care If you are currently in the FEHB
join this Plan Program and are switching to us your former plan will pay for the hospital stay until You are discharged not merely moved to an alternative care center or
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 Your Plan physician will arrange your referral to a specialist Except in a medical emergency or
specialty care when a Plan physician has designated another doctor to see his or her patients you must receive a referral from your Plan physician before seeing any other doctor or obtaining special services
Referral to a participating specialist is given at the Plan physicians discretion if nonPlan
specialists or consultants are required the Plan physician will arrange appropriate referrals
If you need to see a specialist frequently because of a chronic complex or serious medical
condition your Plan physician will develop a treatment plan that allows you to see your specialist
for a certain number of visits without additional referrals Your Plan physician will use our criteria
when creating your treatment plan
What do I do if I am Your Plan physician will decide what treatment you need If the doctor who originally referred
seeing a specialist you to this specialist is now your Plan doctor you need only call to explain that you are now a
when I enroll Plan member and ask that you be referred to your next appointment If your doctor decides to refer you to a specialist ask if you can see your current specialist If you are selecting a new Plan
doctor and want to continue with this specialist you must schedule an appointment so that the
Plan physician can decide whether to treat the condition directly or refer you back to the specialist
If your current specialist does not participate with 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
What do I do if my Call your Plan physician who will arrange for you to see another specialist You may receive
specialist leaves the services from your current specialist until we can make arrangements for you to see someone else
Plan
5
7
7
Page 8
9
HEALTH ALLIANCE PLAN 2000
Section 3 How to get benefits continued
But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to
serious illness and my continue seeing your provider for up to 90 days after we notify you that we are terminating our
provider leaves the contract with the provider unless the termination is for cause If you are in the second or third
Plan or this Plan trimester of pregnancy you may continue to see your OBGYN until the end of your postpartum
leaves the Program 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 may 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 may pay for the OBGYN
care you receive from your current provider until the end of your postpartum care
How do you Your physician must get our approval before sending you to a hospital referring you to a special
authorize ist or recommending followup care Before giving approval we consider if the service is
medical services medically necessary and if it follows generally accepted medical practices This Plan will provide benefits for Mental ConditionsSubstance Abuse care only when the services are medically
necessary to prevent diagnose or treat your illness or condition You must call HAPs Coordi
nated Behavioral Health Management CBHM For details see page 14 A referral from your
Plan doctor is not necessary
How do you decide if For the purposes of this Contract HAP bases its determination of whether or not a drug treat
a service is ment device procedure service or benefit is experimental or investigational in nature if it meets
experimental any of the following criteria
or investigational It cannot be lawfully marketed without the approval of the FDA and such approval has not been granted at the time of its use or proposed use or is the subject of current investigational
new drugs or device applications with the FDA
It is being provided pursuant to a Phase I or Phase II clinical trial or as the experimental or
research arm of a Phase III clinical trial or is the subject of written protocol which describes its
objective determinations of safety efficacy efficacy in comparison to conventional alterna
tives of toxicity
It is being delivered or should be delivered subject to the approval and supervision of an
Institutional Review Board as required and defined by federal regulations particularly those to
the FDA or the Department of Health and Human Service
The predominant opinion among experts as expressed in the published authoritative literature is
that usage should be substantially confined to research settings or it is not investigational in
itself pursuant to any of the foregoing criteria and would not be medically necessary but for
the provision of a drug device treatment or procedure which is investigational or experimen
tal
Medical services which are generally regarded by the medical community to be unusual
infrequently provided and not necessary for the protection of health
6
8
8
Page 9
10
HEALTH ALLIANCE PLAN 2000
Section 4 What to do if we deny your claim or request for service
If we deny services or wont pay your claim you may ask us to reconsider our decision Your request must
Be in writing
Refer to specific brochure wording explaining why you believe our decision is wrong and
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
Maintain our denial in writing
Pay the claim
Arrange for a health care provider to give you the service or
Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30
days after we receive the additional information If we do not receive the requested information within 60 days we will make our
decision based on the information we already have
When may I ask You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal
OPM to review a OPM will determine if we correctly applied the terms of our contract when we denied your claim
denial or request for service
What if I have a Call us at 313 8728100 or 18004224641 and we will expedite our review
serious or life
threatening condition
and you havent
responded to my
request for service
What if you have If we expedite your review due to a serious medical condition and deny your claim we will
denied my request inform OPM so that they can give your claim expedited treatment too Alternatively you can call
for care and my OPMs health benefits Division III at 202 6060755 between 8 am and 5 pm Serious or life
condition is serious threatening conditions are ones that may cause permanent loss of bodily functions or death if they
or life threatening are not treated as soon as possible
Are there other time You must write to OPM and ask them to review our decision within 90 days after we uphold our
limits initial denial or refusal of service You may also ask OPM to review your claim if
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
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
7
9
9
Page 10
11
HEALTH ALLIANCE PLAN 2000
Section 4 What to do if we deny your claim or request for service continued
What do I send to Your request must be complete or OPM will return it to you You must send the following
OPM information
A statement about why you believe our decision is wrong based on specific benefit provisions
in this brochure
Copies of documents that support your claim such as physicians letters operative reports
bills medical records and explanation of benefits EOB forms
Copies of all letters you sent us about the claim
Copies of all letters we sent you about the claim and
Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to
which claim
Who can make the Those who have a legal right to file a disputed claim with OPM are
request Anyone enrolled in the Plan
The estate of a person once enrolled in the Plan and
Medical providers legal counsel and other interested parties who are acting as the enrolled
persons representative They must send a copy of the persons specific written consent with
the review request
Where should I mail Send your request for review to Office of Personnel Management Office of Insurance Programs
my disputed claim to Contract Division III PO Box 436 Washington DC 20044
OPM
What if OPM OPMs decision is final There are no other administrative appeals If OPM agrees with our
upholds the Plans decision your only recourse is to sue
denial If you decide to sue you must file the suit against OPM in Federal court by December 31 of the
third year after the year in which you received the disputed services or supplies
What laws apply if I Federal law governs your lawsuit benefits and payment of benefits The Federal court will base
file 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 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
8
10
10
Page 11
12
HEALTH ALLIANCE PLAN 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 Xrays Within the service area house
calls will be provided if in the judgement of the Plan doctor such care is necessary and appropri
ate you pay nothing for a doctors house call or for home visits by nurses and health aids
The following services are included and are subject to the office visit copay unless stated other
wise
Preventive care including wellbaby care and periodic checkups
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 to 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
Consultations by specialists
Diagnostic procedures such as laboratory tests and Xrays
Complete obstetrical maternity care for all covered females including prenatal delivery and
postnatal care by a Plan doctor or certified nurse midwife The mother at her option may
remain in the hospital up to 48 hours after a regular delivery and 96 hours after a caesarean
delivery Inpatient stays will be extended if medically necessary 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 mothers
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 and family planning services
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heartlung kidney lung single and double and liver 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 Hodgkins lymphoma advanced nonHodgkins lymphoma
advanced neuroblastoma breast cancer multiple myeloma epithelial ovarian cancer and
testicular mediastinal retroperitoneal and ovarian germ cell tumors Transplants are covered
when approved by the Medical Director Related medical and hospital expenses of the donor
are covered when the recipient is covered by this Plan
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
Surgical treatment of morbid obesity
Orthopedic devices such as braces
Prosthetic devices such as breast prostheses or surgical bras and their replacements artificial
limbs and lenses following cataract removal
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 9
11
11
Page 12
13
HEALTH ALLIANCE PLAN 2000
Section 5 Benefits continued
Medical and Surgical Benefits continued
What is covered Durable medical equipment such as wheelchairs and hospital beds
continued 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
Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip 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 All other procedures involving the teeth or intraoral
areas surrounding the teeth are not covered
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 affect on the members appearance and if
the condition can reasonably be expected to be corrected by such surgery
Shortterm rehabilitative therapy physical speech and occupational is covered in full on an
inpatient or outpatient basis for up to 60 visits per condition if significant improvement can be
expected within 60 visits you pay nothing Speech therapy is limited to treatment of certain
speech impairments of organic origin Occupational therapy is limited to services that assist the
member to achieve and maintain self care and improved functioning in other activities of daily
living
Diagnosis and treatment of infertility is covered you pay a 10 copay per office visit The
following types of artificial insemination are covered intravaginal insemination IVI intracervi
cal ICI and intrauterine insemination IUI Cost of donor sperm is not covered Fertility drugs
are covered under the Prescription Drug Benefit Other assisted reproductive technology ART
procedures such as invitro fertilization and embryo transfer are not covered
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is
provided for up to 12 visits you pay nothing on an outpatient basis Cardiac rehabilitation while
you are an inpatient is covered in full
What is not covered Physical 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 voluntary surgicallyinduced sterility
Surgery primarily for cosmetic purposes
Transplants not listed as covered
Hearing aids
Longterm rehabilitative therapy
Chiropractic services
Homemaker services
Foot orthotics
Physician equipment
Medical equipment needed only for comfort or convenience
Replacement or repair of any medical equipment or prosthetic or orthopedic device due to
misuse
Eyeglasses or contact lenses including the fitting of contact lenses except as necessary for the
first pair of corrective lenses following cataract surgery
10 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
12
12
Page 13
14
HEALTH ALLIANCE PLAN 2000
Section 5 Benefits continued
HospitalExtended 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 nursing care
Specialized care units such as intensive care or cardiac care units
Extended Care
The Plan provides a comprehensive range of benefits when fulltime skilled nursing care is
necessary and confinement in a skilled nursing facility is medically appropriate as determined by a
Plan doctor The Plan pays for up to 730 days each continuous period of confinement or for
successive periods separated by less then 60 days This 730 day period will be reduced by two
days for every inpatient hospital day prior to admission to a skilled nursing facility A new period
of 730 days will begin after at least 60 days have elapsed from the last date of discharge 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 hospice
facility Services include inpatient and outpatient care and family counseling those services
which are provided under the direction of a Plan doctor who certified that the patient is in the
terminal stages of illness with a life expectancy of approximately six months or less This benefit
is limited to 210 days per member per lifetime
Ambulance Service
Benefits are provided for emergency ambulance transportation ordered or authorized by a Plan
doctor
Limited benefits Inpatient Dental Procedures Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a
need for hospitalization for reasons 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 Detoxification
Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis
treatment of medical conditions and medical management of withdrawal symptoms acute
detoxification if the Plan doctor determines that outpatient management is not medically appro
priate See page 14 for nonmedical substance abuse benefits
What is not covered Personal comfort items such as telephone and television
Custodial care rest cures domiciliary or convalescent care
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11
13
13
Page 14
15
HEALTH ALLIANCE PLAN 2000
Section 5 Benefits continued
Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or injury that you believe
emergency endangers your life or could result in a 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 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
Emergencies Within If you are in an emergency situation please call your Plan physician In extreme emergencies if
the Service Area you are unable to contact your doctor contact the local emergency system eg the 911 telephone system or go to the nearest hospital emergency room Be sure to tell the emergency room
personnel that you are a Plan member so they can notify the Plan You or a family member should
notify the Plan within 48 hours unless it is not reasonably possible to do so It is your responsibil
ity to ensure that the Plan has been timely notified
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working
day following your admission unless it was not reasonably possible to notify the Plan within that
time If you are hospitalized in nonPlan facilities and Plan doctors believe care can be better
provided in a Plan hospital you will be transferred when medically feasible with any ambulance
charges covered in full
Benefits are available for any care from nonPlan 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 followup care recommended by nonPlan providers must be
approved by the Plan and 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 Nothing per visit for emergency care services that are covered benefits of this Plan
Emergencies outside Benefits are available for any medically necessary health service that is immediately required
the Service Area because of injury or unforeseen illness
If you need to be hospitalized the Plan must be notified within 48 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 trans
ferred when medically feasible with any ambulance charges covered in full
To be covered by this Plan any followup care recommended by nonPlan providers must be
approved by the Plan and 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 Nothing per visit for emergency care services that are covered benefits of this Plan
12
14
14
Page 15
16
HEALTH ALLIANCE PLAN 2000
Section 5 Benefits continued
Emergency Benefits continued
What is covered Emergency care at a doctors office or an urgent care center
Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service approved by the Plan
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
Medical and hospital costs resulting from a normal fullterm delivery of a baby outside the
service area
Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency
nonPlan providers care 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 Plans decision you
may request reconsideration in accordance with the disputed claims procedure described on page 7
13
15
15
Page 16
17
HEALTH ALLIANCE PLAN 2000
Section 5 Benefits continued
Mental ConditionsSubstance Abuse Benefits
Mental Conditions You must call HAPs Coordinated Behavioral Health Management CBHM at 18004445755
prior to services rendered The Plan will determine and authorize the appropriate number of visits
A referral from your Plan physician is not required
What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions including the treatment of mental illness or disor
ders
Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Outpatient Care Up to 20 outpatient visits to Plan doctors consultants or other psychiatric personnel each calen dar year you pay a 5 copay for each covered visit The plan will determine and authorize the
appropriate number of visits The referral from your plan physician is not required
Inpatient Care All services up to 30 days of hospitalization each benefit period You pay nothing for the first 30 daysall charges thereafter A new benefit period begins when there has been a lapse for 60
consecutive days from the last day of discharge from a hospital
What is not covered Care for psychiatric conditions that in the professional judgement of Plan doctors are not subject to significant improvement through relatively shortterm treatment
Psychiatric evaluation or therapy on court order 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 shortterm psychiatric condition
Substance Abuse
What is covered This Plan provides medical and hospital services such as acute detoxification services for the medical nonpsychiatric 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 Up to 35 outpatient visits or State mandated annual aggregate dollar amount whichever is greater each calendar year you pay a 5 copay for each covered visitall charges thereafter
The substance abuse benefits may be combined with the outpatient mental conditions benefits
shown on this page provided such treatment is necessary and is approved by the Plan to permit an
additional 20 outpatient visits per calendar year with the applicable mental benefit copayments
Inpatient care All services up to 30 days per benefit period You pay nothing during the first 30 days of each benefit period all charges thereafter A new benefit period begins when there has been a lapse
of 60 consecutive days from the last day of discharge from a hospital
What is not covered Treatment that is not authorized by a Plan doctor
14 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
16
16
Page 17
18
HEALTH ALLIANCE PLAN 2000
Section 5 Benefits continued
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 35day supply you pay a 2 copay per prescription unit or refill Generic
maintenance drugs are covered up to a 100unit dose or a 35day supply whichever is greater for
the 2 copay per prescription unit or refill The cost of prescriptions filled at nonPlan pharmacies
are reimbursable to the enrollee minus the 2 copay per prescription or refill
Covered medications and accessories include
Drugs for which a prescription is required by law
Contraceptive drugs including injectable contraceptive drugs and devices that require a
prescription such as diaphragms
Fertility drugs
Insulin
Compounded dermatological preparations
Implanted timerelease medications such as Norplant For Norplant you pay a 10 office visit
copay per prescription For other internally implanted timerelease medications you pay a 10
office visit copay There is no charge when the device is implanted during a covered hospital
ization
Smoking cessation drugs and medication including nicotine patches
Disposable needles and syringes needed to inject covered prescribed medication
Intravenous fluids and medication for home use are covered under Medical and Surgical
Benefits
Injectable medications
Limited Benefits Sexual dysfunction drugs have dispensing limitations 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 nonPlan pharmacy except for outofarea emergencies
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 15
17
17
Page 18
19
HEALTH ALLIANCE PLAN 2000
Section 5 Benefits continued
Other Benefits
Dental Care
Accidental injury Restorative services and supplies necessary to promptly repair but not replace sound natural
benefit teeth The need for these services must result from an accidental injury not biting or chewing You pay nothing
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 diagnosis and treatment of diseases of the eye annual eye refractions to provide a written lens prescription for eyeglasses may be
obtained from Plan providers You pay 10 copay per visit
What is not covered Corrective eyeglasses and frames or contact lenses except for cataract lenses
Exams specifically for the purpose of fitting contact lenses
Eye exercise
16 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
18
18
Page 19
20
HEALTH ALLIANCE PLAN 2000
NonFEHB 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 who are members of this Plan The cost of the benefits de
scribed on this page is not included in the FEHB premium and any charges for these services do not count toward any
FEHB deductibles or outofpocket maximums These benefits are not subject to the FEHB disputed claims proce
dures
A MailOrder Prescription Drug Program is also available for a 4 copayment up to a 90day supply Please contact
the Plan for information about the Mail Order Program
Medicare 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 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 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
prepaid plan Contact us at 313 8728100 for information on the Medicare prepaid Plan and the cost of that enroll
ment
If you are Medicare eligible and are interested in enrolling in a Medicare HMO sponsored by this Plan without
dropping your enrollment in this Plans FEHB plan call 313 8728100 for information on the benefits available
under the Medicare HMO
Benefits on this page are not part of the FEHB contract
17
19
19
Page 20
21
HEALTH ALLIANCE PLAN 2000
Section 6 General exclusions Things we dont 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 Services drugs or supplies that are not medically necessary
following Services not required according to accepted standards of medical dental or psychiatric
practice
Care by nonPlan 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
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
18
20
20
Page 21
22
HEALTH ALLIANCE PLAN 2000
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 MedicareChoice 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
MedicareChoice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a MedicareChoice plan contact your retirement office If you
later want to reenroll in the FEHB Program generally you may do so only at the next Open
Season
If you involuntarily lose coverage or move out of the MedicareChoice 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 MedicareChoice plans contact your local Social Security Administration
SSA office or request it from SSA at 18006386833
Other group When anyone has coverage with us and with another group health plan it is called double
insurance coverage You must tell us if you or a family member has double coverage You must also send us
coverage 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
Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to
beyond provide them In that case we will make all reasonable efforts to provide you with necessary care
our control
When others are When you receive money to compensate you for medical or hospital care for injuries or illness
responsible that another person caused you must reimburse us for whatever services we paid for We will
for injuries 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
19
21
21
Page 22
23
HEALTH ALLIANCE PLAN 2000
Section 7 Limitations Rules that affect your benefits continued
Workers We do not cover services that
Compensation You need because of a workplacerelated disease or injury that the Office of Workers Com
pensation Programs OWCP or a similar Federal or State agency determine they must provide
OWCP or a similar agency pays for through a third party injury settlement or other similar
proceeding that is based on a claim you filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment we will
provide your benefits
Medicaid We pay first if both Medicaid and this Plan cover you
Other government We do not cover services and supplies that a local State or Federal Government agency directly
agencies or indirectly pays for
20
22
22
Page 23
24
HEALTH ALLIANCE PLAN 2000
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
information about right to information about your health plan its networks providers and facilities You can also
your HMO find out about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPMs website
wwwopmgov lists the specific types of information that we must make available to you
If you want specific information about us call 313 8728100 or 18004224641 or write to
2850 W Grand Blvd Detroit MI 48202 You may also contact us by fax at 313 6648400 or
visit our website at wwwhapcorporg
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal
information about Employees Health Benefits Plans brochures for other plans and other materials you need to make
enrolling in the an informed decision about
FEHB Program When you may change your enrollment
How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter
military service or retire
When your enrollment ends and
The next Open Season for enrollment
We dont determine who is eligible for coverage and in most cases cannot change your enroll
ment status without information from your employing or retirement office
When are my The benefits in this brochure are effective on January 1 If you are new to this Plan your coverage
benefits and and premiums begin on the first day of your first pay period that starts on or after January 1
premiums effective Annuitants premiums begin January 1
What happens when When you retire you can usually stay in the FEHB Program Generally you must have been
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 Continua
tion of Coverage which is described later in this section
What types of SelfOnly coverage is for you alone Self and Family coverage is for you your spouse and your
coverage are unmarried dependent children under age 22 including any foster or step children your employing
available for my or retirement office authorizes coverage for Under certain circumstances you may also get
family and me 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
21
23
23
Page 24
25
HEALTH ALLIANCE PLAN 2000
Section 8 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 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 subro
gating claims
Law enforcement officials when investigating andor 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
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 Your old plans deductible continues until our coverage begins
deductible under my
old plan
Preexisting We will not refuse to cover the treatment of a condition that you or a family member had before
conditions 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 Your enrollment ends unless you cancel your enrollment or
Plan ends You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits
spouse coverage under your former spouses 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 exspouses 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 705 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 You can pick a new plan
TCC 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
22
24
24
Page 25
26
HEALTH ALLIANCE PLAN 2000
Section 8 FEHB FACTS continued
Key points about If you or your employing office delay processing your request you still have to pay premiums
TCC continued from the 32nd day after your regular coverage ends even if several months have passed
You pay the total premium and generally a 2percent administrative charge The government
does not share your costs
You receive another 31day 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 If you leave Federal service your employing office will notify you of your right to enroll under
TCC TCC You must enroll within 60 days of leaving or receiving this notice whichever is later
Children You must notify your employing or retirement office within 60 days after your child is
no longer an eligible family member That office will send you information about enrolling in
TCC You must enroll your child within 60 days after they become eligible for TCC or receive
this notice whichever is later
Former spouses You or your former spouse must notify your employing or retirement office
within 60 days of one of these qualifying events
Divorce
Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about enroll
ing 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 60day deadline
How can I convert to You may convert to an individual policy if
individual coverage Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did
not pay your premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is
available You must apply in writing to us within 31 days after you receive this notice However if
you are a family member who is losing coverage the employing or retirement office will not
notify you You must apply in writing to us within 31 days after you are no longer eligible for
coverage
Your benefits and rates will differ from those under the FEHB Program however you will not
have to answer questions about your health and we will not impose a waiting period or limit your
coverage due to preexisting conditions
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage
Certificate of Group that indicates how long you have been enrolled with us You can use this certificate when getting
Health Plan health insurance or other health care coverage You must arrange for the other coverage within 63
Coverage 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
23
25
25
Page 26
27
HEALTH ALLIANCE PLAN 2000
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 313 8728100 and explain the situation
If we do not resolve the issue call or write
THE HEALTH CARE FRAUD HOTLINE
2024183300
US 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
24
26
26
Page 27
28
HEALTH ALLIANCE PLAN 2000
Summary of Benefits for Health Alliance Plan 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 PaysProvides Page
Inpatient Care Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes inhospital
doctor care room and board and 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 11
Extended Care Up to 730 days per member per confinement You pay nothing 11
Mental Conditions Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per benefit
period You pay nothing 14
Substance Abuse Up to 30 days of inpatient substance abuse care per benefit period You pay nothing 14
Outpatient Care Comprehensive range of services such as diagnosis and treatment of illness or injury including specialists
care preventive care including wellbaby care periodic checkups and routine immunizations laboratory
tests and Xrays complete maternity care
You pay a 10 copay per office visit nothing for house calls by a doctor 11
Home Health Care All medically necessary visits by nurses and health aides You pay nothing 11
Mental Conditions Up to 20 outpatient visits per year You pay a 5 copay per visit 14
Substance Abuse Up to 35 outpatient visits per year You pay a 5 copay per visit 14
Emergency Care Reasonable charges for services and supplies required because of a medical emergency
You pay nothing for emergency room visits 11
Prescription
Drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy
You pay a 2 copay per prescription unit or refill 15
Dental Care Accidental injury benefit You pay no copay per visit 16
Vision Care Eye refractions for eyeglasses You pay a 10 copay per refraction 16
OutofPocket
Maximum Your outofpocket expenses for benefits under this Plan are limited to the stated copayments
required for a few benefits 4
27
27
Page 28
HEALTH ALLIANCE PLAN 2000
2000 Rate Information for Health Alliance Plan
NonPostal rates apply to most nonPostal 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 US Postal Service employees In 2000 two categories of contribution rates referred to as Cat
egory 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 702 to determine which rate applies to you
Postal rates do not apply to noncareer 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
NonPostal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Govt Your Govt Your USPS Your USPS Your
Enrollment Code Share Share Share Share Share Share Share Share
Self Only 521 6621 2207 14345 4782 7835 993 7835 993
Self and Family 522 17545 5848 38014 12671 20761 2632 20102 3291
28