Pages 1--31 from Ri-73016

5.Brochuresare
availablein
Spanish

Enrollment code
891 Self only
892 Self and Family

Visit the OPM website at http www opm gov insure
and
this Plan's website at http www ssspr com

Authorized for distribution by the
United United United United United States States States States States
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PP PPer P er er ersonnel er sonnel sonnel sonnel sonnel
Management Management Management Management Management

RI 73 016 1
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Triple S 2000
Table of Contents
Page
Introduction 3

Plain language 3
How to use this brochure 4
Section 1 Health Maintenance Organizations 5
Section 2 How we change for 2000 5
Section 3 How to get benefits 6
Section 4 What to do if we deny your claim or request for service 8
Section 5 Benefits 10
Section 6 General exclusions Things we don't cover 20
Section 7 Limitations Rules that affect your benefits 21
Section 8 FEHB Facts 23
Department of Defence FEHB Demonstration Project 26
Inspector General Advisory Stop Healthcare Fraud 28
Summary of benefits 29
Rate information back cover

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Triple S 2000
Introduction

Triple S Inc Triple S 1441 Roosevelt Avenue San Juan Puerto Rico 00920
This brochure describes the benefits you can receive from Triple S under its contract CS1090 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 5 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 Triple S 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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Triple S 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 with a Point of Service Product 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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Triple S 2000
Section 1 Health Maintenance Organizations

This Plan is a health maintenance organization HMO that offers a point of service or POS product Whenever you need
services you may choose to obtain them from your personal doctor within the Plan's provider network or go outside the network
for treatment Within the Plan's network you are encouraged to select a personal doctor who will provide or arrange for your
care and you will pay minimal amounts for comprehensive benefits copayments and coinsurance listed in this brochure There
are no claims forms when plan doctors are used When you choose a non Plan doctor or other non Plan provider you will pay a
substantial portion of the charges and the benefits available may be less comprehensive

You should join an HMO because you prefer this 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

Because the Plan provides or arranges your care and pays the cost it seeks efficient and effective delivery of health services By
controlling unnecessary or inappropriate care it can afford to offer a comprehensive range of benefits In addition to providing
comprehensive health services and benefits for accidents illness and injury the Plan emphasizes preventive benefits such as
office visits physicals immunizations and well baby care You are encouraged to get medical attention at the first sign of illness

Section 2 How we change for 2000
Program wide This year you have a right to more information about this Plan care management our networks facilities
changes and providers

If you have a chronic or disabling condition and your provider leaves this Plan at our request you may
continue to see your specialist for up to 90 days If your provider leaves this 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

You pay a 7.50 copay per office visit to a Plan doctor general practitioner and 10 copay per office visit to a Plan doctor specialist except for mental conditions and substance abuse as explained on Section 5

Benefits
Clarifications Authorization from this Plan is required before genetic amniocentesis single photon emission computerized
regarding this Plan tomography SPECT hepatobiliary ductal system imaging HIDA magnetic resonance imaging MRI magnetic resonance angiography MRA lithotripsy computerized tomography and

polysomnography
Authorization from this Plan is required before hospital admissions Admissions due to an emergency
including normal and cesarean deliveries do not require prior authorization but must be
notified to Triple S on or before the following workday

Air ambulance services will not be covered if services are rendered outside of Puerto Rico

Breast prostheses and surgical bras as well as their replacement are covered
New drugs not approved by the Plan's Pharmacy and Therapeutic Committee are not covered
FDA approved prescription drugs and devices for birth control are covered

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Triple S 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 Only the Commonwealth of Puerto Rico

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 or point of service benefits 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
This Plan offers reciprocity with the Blue Cross Blue Shield network through the BlueCard Program 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 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 as explained on Section 5 Benefits

Do I have to submit You normally won't have to submit claims to us unless you receive emergency services from a provider
claims who doesn't contract with us or you use point of service benefits 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 Triple S is an individual practice prepayment plan You can receive care from any Plan doctor A Plan
health care doctor is a doctor of medicine M D licensed to practice in the Commonwealth of Puerto Rico who has agreed to accept the Triple S established fees as payment in full for surgery and certain other services If

you use a non Plan doctor except for speech or occupational therapy you must pay the difference between
the non Plan doctor's charge and the amount paid to you by Triple S A non Plan doctor is any licensed
doctor of medicine M D who is not a Plan doctor Non Plan doctors do not have to accept Triple S
established fees as payment in full Most doctors practicing in Puerto Rico are Plan doctors

You can also receive services from a Plan hospital This is a licensed general hospital in Puerto Rico that
has signed a contract with Triple S to render hospital services to persons insured by Triple S A non Plan
hospital is any licensed institution that is not a Plan hospital and that is engaged primarily in providing bed
patient with diagnosis and treatment under the supervision of physicians with 24 hour a day registered
graduate nursing services You must pay any difference between the non Plan hospital's charges and the
amount paid to you by Triple S

Benefits are paid according to the medical benefits schedule This is the schedule of established fees on
which this Plan's payment of covered medical expense is based when the services are rendered within the
service area The medical benefits schedule applies to Puerto Rico When services are rendered outside the
area this Plan pays usual customary and reasonable charges

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

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

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Triple S 2000
What do I do if I'm First call our Customer Service Department at 787 749 4777 If you are new to the FEHB Program we
in the hospital when will arrange for you to receive care If you are currently in the FEHB Program and are switching to us your
I join this Plan 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 You are encouraged to select a primary care doctor e g family practitioner internist pediatrician OBGYN
specialty care for you and for each family member Your primary care doctor can help coordinate your care

What do I do if I am If your current specialist does not participate with us you must receive treatment from a specialist who
seeing a specialist does Generally we will not pay for you to see a specialist who does not participate with our Plan
when I enroll

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 this services from your current specialist until we can make arrangements for you to see someone else
Plan

But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to continue seeing
serious illness and your provider for up to 90 days after we notify you that we are terminating our contract with the provider
my provider leaves unless the termination is for cause If you are in the second or third trimester of pregnancy you may
this Plan or this Plan continue to see your OB GYN until the end of your postpartum care
leaves the Program 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 Your physician must get our approval before sending you to a hospital Before giving approval we consider
authorize medical if the service is medically necessary and if it follows generally accepted medical practice
services This Plan will provide benefits for covered services only when services are medically necessary to prevent

diagnose or treat your illness or condition Your Plan doctor will determine medical necessity but you must
obtain authorization from this Plan before services outside the Service Area except emergencies rental
and purchase of durable medical equipment Skilled Nursing Facility organ and tissue transplants hospitalization
for certain inpatient dental procedures genetic amniocentesis single photon emission computerized
tomography SPECT hepatobiliary ductal system imaging HIDA magnetic resonance imaging
MRI magnetic resonance angiography MRA lithotripsy computerized tomography and
polysomnography

Magnetic Resonance Imaging MRI rehabilitation therapy and lithotripsy also require an authorization
Your provider will obtain the authorization

Also mental and substance abuse and hospital admissions require an authorization You or your Plan
doctor must obtain the required authorizations

How do you decide if This Plan considers factors which it determines to be most relevant under the circumstances such as
a service is published reports and articles in the authoritative medical scientific and peer review literature or
experimental or written protocols used by the treating facility or being used by another facility studying substantially
investigational the same drug device or medical treatment This Plan also considers Federal and other governmental agency approval as essential to the treatment of an injury or illness by but not limited to the

following American Medical Association U S Surgeon General U S Department of Public Health
the Food and Drug Administration or the National Institutes of Health

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Triple S 2000
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 You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal OPM will
OPM to review a determine if we correctly applied the terms of our contract when we denied your claim or request for
denial service

What if you have If we expedite your review due to a serious medical condition and deny your claim we will inform OPM so
denied my request that they can give your claim expedited treatment too Alternatively you can call OPM's health benefits
for care and my Contract Division II at 202 606 3818 between 8 a m and 5 p m Serious or life threatening conditions are
condition is serious ones that may cause permanent loss of bodily functions or death if they are not treated as soon as possible
or life threatening

What if I have a Call us at 787 749 4777 and we will expedite our review
serious or life
threatening
condition and you
haven't responded to
my request for
service

Are there other time You must write to OPM and ask them to review our decision within 90 days after we uphold our initial
limits 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

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Triple S 2000
What do I send to Your request must be complete or OPM will return it to you You must send the following information
OPM 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 person's
representative They must send a copy of the person's specific written consent with the review request

What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our decision your
upholds the Plan's 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 its review
file a lawsuit 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 Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and us to
the Privacy Act 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

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Triple S 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 7.50 copay for each office visit

to a Plan doctor general prectitioner a 10 copay for each office visit to a Plan doctor specialist and 25
of the fee schedule allowance for laboratory and diagnostic tests out of hospital but no additional copayment
for X ray examinations You must use a Triple S participating laboratory and X ray facility Within the
service area house calls will be provided if in the judgement of the Plan doctor such care is necessary
and appropriate you pay a 15 copay for a doctor's house call and nothing for home visits by nurses and
health aides The physician may charge a differential to a member who requests a private room in the
hospital if semiprivate rooms are available The physician will bill the Plan on the basis of the established
fees for such purposes and will charge the member any difference directly

If you use a non Plan doctor you pay for services rendered and the Plan will reimburse you 1 90 of the
Plan's established fee when services are rendered within the service area or 2 90 of the usual customary
and reasonable charge of the area in which the services are rendered when services are rendered
outside the service area You also pay a 7.50 copay for each office visit to a non Plan doctor general
prectitioner a 10 copay for each office visit to a non Plan doctor specialist a 15 copay per doctor's
house call and nothing for visits of nurses and health aides

The following services are included
Preventive care including well baby care and periodic check ups

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
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays You or your Plan doctor must obtain authorization from your Plan before genetic amniocentesis single photon emission computerized tomography
SPECT hepatobiliary ductal system imaging HIDA magnetic resonance imaging MRI magnetic
resonance angiography MRA lithotripsy computerized tomography and polysomnography as discussed
on Page 7

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 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 this 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 and family planning services
Tuboplasty
Diagnosis and treatment of diseases of the eye

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Triple S 2000
What is covered 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 This Plan pays 100
of the submitted charge when the implant device is provided and billed by a Plan doctor or provider If
the implant device is provided and billed by a non Plan doctor provider or medical equipment supplier
this Plan will reimburse you 90 of the established fee

Breast prostheses and surgical bras as well as their replacement
Cornea heart heart lung lung kidney kidney pancreas 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
Hodgkin's lymphoma advanced non Hodgkin's lymphoma advanced neuroblastoma breast cancer
multiple myeloma epithelial ovarian cancer and testicular mediastinal retro peritoneal and ovarian
germ cell tumors Transplants are covered when approved by this Plan Related medical and hospital
expenses of the donor are covered when the recipient is covered by this Plan You must obtain authorization
from your Plan before an organ or tissue transplant as discussed on Page 7

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
Lenses following cataract removal
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

All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and
other Plan providers

The medical management of mental conditions will be covered under this Plan's Medical and Surgical
Benefits provisions Related drug costs will be covered under this Plan's Prescription Drug Benefits and
any costs for psychological testing or psychotherapy will be covered under this Plan's Mental Conditions
Benefits Office visits for the medical aspects of treatment do not count toward the 40 outpatient Mental
Conditions visit limit

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 Mandibular and maxillary osteotomy are also covered All other procedures involving
the teeth or intra oral areas surrounding the teeth are not covered including shortening of the mandible or
maxillae for cosmetic purposes and any dental care involved in treatment of temporomandibular joint
TMJ pain dysfunction syndrome

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Triple S 2000
Limited benefits 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

Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient
basis for up to two consecutive months per condition if significant improvement can be expected
within two months Physical therapy must be provided by or under the supervision of a doctor specializing
in physical therapy and speech and occupational therapy must be referred by a Plan doctor to a provider
certified to provide such therapy you pay a 10 copay per outpatient session and nothing per inpatient
session There are no participating Plan providers for speech therapy and occupational therapy 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 As discussed on page 6 of this brochure you should pay the
provider's claim and seek reimbursement from this Plan

Diagnosis and treatment of infertility is covered excluding drug treatment you pay a 10 office visit
copay Artificial insemination is covered you pay a 10 office visit copay the cost of donor sperm is not
covered Fertility drugs are not covered Other assisted reproductive technology ART procedures such
as in vitro fertilization and embryo transfer are not covered

Respiratory therapy is covered for up to two sessions per day to a maximum of 20 sessions per year
you pay a 10 copayment per session

Second surgical opinions A second surgical opinion is required for certain elective surgeries Your participating
doctor will inform you when a second opinion is required and provide you with a report on your
condition and the need for surgery You must contact this Plan to arrange for a second opinion to be
provided by a consulting physician or Plan medical personnel If the second opinion does not confirm the
medical necessity of the surgery this Plan will refer you to another physician If that physician also determines
the surgery is not medically necessary this Plan will not provide coverage for the surgery The cost
of the second and any additional opinion is covered in full by this Plan

Durable medical equipment is limited to coverage for oxygen equipment wheel chairs hospital type
beds and iron lungs and other respiratory equipment The item will be rented or purchased at this
Plan's discretion and must be prescribed by a Plan doctor and obtained from Plan sources You must
obtain authorization from your Plan before purchase or rental of durable medical equipment as discussed
on page 7

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 surgically induced sterility
Surgery primarily for cosmetic purposes
Transplants not listed as covered
Long term rehabilitative therapy
Hearing aids
Orthopedic devices such as braces foot orthotics
Prosthetic devices such as artificial limbs
Private nursing care except for treatment of mental illness

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Triple S 2000
What is not covered Assistance at surgery services

Podiatric services
Chiropractic services
Homemaker services

Cardiac rehabilitation
Hospital Extended Care Benefits
What is covered
Hospital care This Plan provides a comprehensive range of benefits with no dollar or day limit for a member who is
hospitalized in a participating hospital You or your Plan doctor must request an authorization from
Triple S before hospital admissions Admissions due to an emergency including normal and cesarean
deliveries do not require prior authorization but must be notified to Triple S on or before the
following workday You pay nothing per inpatient admission to a participating hospital in the service
area If you use a non participating hospital this Plan will reimburse 60 per day except for
hospitalization due to accidental injury or a medical emergency as shown on page 14 You pay all
remaining charges All necessary services are covered including

Semiprivate room accommodations including general nursing care meals and special diets If for
any reason a private room is used you must pay the difference between the hospital's charge for
these accommodations and the special rates contracted for by Triple S Also if a private room is
selected you must pay any difference between your physician's normal fee and this Plan's established
fees You can learn the special contract rates for any particular hospital by calling Triple S

Specialized care units such as intensive care or cardiac care units
Outside the service area hospital benefits for special cases that require equipment mode of treatment or
specialist care are not available in Puerto Rico are covered by this Plan However Triple S must approve
the hospitalization of special cases in advance See page 14 for coverage provided for hospitalization due
to accidental injury or medical emergency Plan pays usual customary and reasonable charges of the area
in which hospital services are rendered You pay any charges for services which are not a covered benefit
of this Plan

Extended Care This Plan provides a comprehensive range of benefits in Plan facilities with no dollar or day limit when fulltime
skilled nursing care is necessary and confinement in a skilled nursing facility medically appropriate as
determined by a Plan doctor and approved by this 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

You must obtain authorization from your Plan before a Skilled Nursing Facility confinement as discussed
on Page 7

Ambulance Benefits are provided for terrestrial or maritime ambulance transportation ordered or authorized by a Plan
services doctor This is an indemnity benefit and is payable directly to you after you have paid the claim except for air ambulance services rendered in Puerto Rico by a Plan provider

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Triple S 2000
Limited Benefits
Impatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need for
procedures hospitalization for reasons totally unrelated to the dental procedure this 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 Authorization must be obtained from the Triple S Plan prior to
admission You pay nothing for covered hospital services

Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis treatment
detoxification of medical conditions and medical management of withdrawal symptoms acute detoxification if this Plan
doctor determines that outpatient management is not medically appropriate See page 16 for non medical
substance abuse benefits

What is not covered Personal comfort items such as telephone and television
Custodial care rest cures domiciliary or convalescent care
Air ambulance service outside of Puerto Rico

Hospice Care

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 this 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 primary care doctor In extreme emergencies if you
the service area are unable to contact your doctor contact the local emergency system e g the 911 telephone system or 343 2550 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 this Plan You or a family member should notify this Plan within
48 hours unless it was not reasonably possible to notify this Plan within that time It is your responsibility
to ensure that this Plan has been timely notified

If you need to be hospitalized this Plan must be notified within 48 hours or on the first working day
following your admission unless it was not reasonably possible to notify this 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

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

Plan pays 90 of Plan's established fees for doctor's services and full coverage for other services to the extent the
services would have been covered if received from Plan providers

You pay 5 per hospital emergency room visit or urgent care center visit for services that are covered benefits of this
Plan and any remaining charges In case of emergencies within the service area this Plan has available a 24
hour toll free number Call 1 800 255 4375 for professional medical advise regarding your condition and
to request an authorization When you receive an authorization the 5 copay is waived Also if the emergency
results in admission to a hospital you pay nothing for the inpatient admission

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Triple S 2000
Emergencies outside Benefits are available for any medically necessary health service that is immediately required because of
the service area injury or unforeseen illness

If you need to be hospitalized this Plan must be notified within 48 hours or on the first working day
following your admission unless it was not reasonably possible to notify this 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

Plan pays 90 of usual customary and reasonable charges for the area in which the emergency services are rendered

You pay The copayments shown above for within area benefits
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
Terrestrial or maritime ambulance service approved by this Plan
What is not covered Elective care or non emergency 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 full term delivery of a baby outside the Service Area
Air ambulance service outside of Puerto Rico

Filing claims for With your authorization this Plan will pay benefits directly to the providers of your emergency care upon
non Plan providers 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 this 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 this Plan's decision you may request reconsideration
in accordance with the disputed claims procedure described on page 8

Mental Conditions Substance Abuse Benefits
Mental conditions
What is covered To the extent shown below this Plan provides the following services necessary for the diagnosis and treatment
of acute psychiatric conditions including the treatment of mental illness or disorders Non Plan
providers are under no obligation to accept the Triple S established fees as payment in full You pay all
charges remaining for outpatient care above this Plan's established fee when non Plan providers are used
in addition to the copays noted below You pay only the copays noted below when Plan providers are used
For all other care under this benefit you pay all remaining charges after this Plan has paid benefits

Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services

Outpatient Care For up to 40 full treatment visits per calendar year you pay 5 per visit for visits 1 20 50 of charges
for visits 21 40 all charges thereafter
For up to 40 group therapy visits per calendar year you pay 5 per visit all charges thereafter
For collateral visits with immediate members of the patient's family 5 visits over age 18 20 visits
under age 18 You pay 5 per visit

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Triple S 2000
Inpatient Care Hospital benefits as shown on page 13 for up to 90 days each calendar year in hospitals approved to render these services Two days of partial hospitalization are equivalent to one full day of hospitalization Your
Plan doctor will request an authorization for any mental or substance abuse hospital admission
For necessary professional services this Plan pays its established fees up to the actual charge Covered
services include but are not limited to medical care consultations laboratory and x ray radiotherapy
physiotherapy and psychotherapy

For special nursing care this Plan pays the following when ordered by the attending psychiatrist for
each 8 hour period not to exceed 72 consecutive hours 18 for a registered nurse 12 for a licensed
practical nurse 12 for a psychiatric aide

In or out the Psychological tests if performed by a qualified psychologist up to 35 for a full battery of tests
hospital Electroshock therapy up to 10 treatments in a calendar year Anesthetic for electroshock therapy up to 10 treatments in a calendar year

Electroencephalography

What is not Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to
covered significant improvement through relatively short term treatment
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 when not medically necessary to determine the appropriate treatment of a short term
psychiatric condition
Charges from a residential treatment facility
Benefits not shown as covered above

Substance Abuse
What is covered This 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 Services for the psychiatric aspects are provided in conjunction with mental
conditions benefits shown above Outpatient visits to Plan mental health providers for follow up care and
counseling are covered as well as inpatient services necessary for diagnosis and treatment The mental
conditions benefits visit day limitations and copayments apply to any covered substance abuse care This
Plan provides a 24 hour toll free number to help you obtain the most appropriate care for your mental or
substance abuse related needs Call 1 800 660 4896 for further assistance Your Plan doctor will use this
number also to coordinate any of the mental or substance abuse hospital admissions covered by this Plan

What is not Benefits not shown as covered above
covered Treatment that is not authorized by a Plan doctor

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Triple S 2000
Prescription Drug Benefits
What is covered Prescription drugs dispensed within six months of a doctor's original prescription not to exceed the normal supply Nonformulary drugs will be covered when prescribed by a Plan doctor You pay 20 coinsurance
up to a maximum of 10 per brand name prescription unit or refill or nothing per generic bioequivalent
prescription unit or refill If you use a non Plan pharmacy this Plan will reimburse you 75 of this Plan's
established fees for prescription drugs and you pay all remaining charges Coinsurance copayment amounts
also apply to disposable needles and syringes

Covered medications and accessories include
Drugs for which a prescription is required by law
Insulin

Vitamins only if they include the legend Federal law prohibits dispensing without a prescription
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 implantable drugs and some injectable drugs are
covered under Medical and Surgical Benefits also covered under Medical and Surgical Benefits
when provided as part of a home health service program

FDA approved prescription drugs and devices for birth control

What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available
Medical supplies such as dressings and antiseptics

Drugs supplied by pharmacies located outside of Puerto Rico the United States and its territories
Medication for the treatment of infertility or impotence
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Implanted time release medications such as Norplant
Drugs that are experimental or investigational unless approved by the Federal Drug Administration FDA

New drugs not approved by the Plan's Pharmacy and Therapeutic Committee

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Triple S 2000
Other Benefits
Dental care
What is covered This Plan provides the following dental coverage shown below you pay 30 of this Plan's established fees
for all services and nothing for oral examination prophylaxis fluoride treatment and x ray services if a
Plan dentist is used If a non Plan dentist is used you pay a 30 coinsurance and any remaining difference
between this Plan's payment of 90 of its established fee and the actual charge for services rendered in
Puerto Rico For care outside of Puerto Rico the member will pay the 30 coinsurance and any remaining
difference between 100 of this Plan's payment established fee and the actual charge The following list
shows the dental services covered by this Plan Coverage is limited to these items

Diagnostic
Periodic oral evaluation
Limited oral evaluation
Comprehensive oral evaluation
Periapical and bitewing x rays limited to six periapical x rays per calendar year and no more than two
bitewing x rays per calendar year
Preventive Prophylaxis adult child
Fluoride treatment one every six month Fluoride treatment is limited to members under 19 years of age

Restorative
Amalgam restorations
Plastic porcelain or composite anterior and posterior tooth Other restorative services pin retention per tooth in addition to restorations

Sedative filling
Adjunctive General ServicesApplication of desensitizing medicament Gingival curettage surgical emergency treatment for one or two teeth in the same quadrant

treatment of complications post surgical unusual circumstances by report
Endodontics
Pulp capping direct excluding final restoration

Pulp capping indirect excluding final restoration
Oral and Maxillofacial Surgery

Extractions
Surgical removal of erupted tooth
Surgical removal of residual tooth roots Incision and drainage of abscess intra oral soft tissue

Impacted tooth

Accidental injury Restorative services and supplies necessary to promptly repair but not replace sound natural teeth are
benefit covered The need for these services must result from an accidental injury An injury caused by chewing
is not considered an accidental injury

Definitions Plan dentist Means a duly authorized dentist with a regular license issued by the designated entity of the
government of Puerto Rico and who is a member bona fide of the Colegio de Cirujanos Dentistas de
Puerto Rico who has signed a contract with Triple S to render dental services

Non Plan dentist Means a duly authorized dentist with a regular license who has not signed a contract
with Triple S to render dental services

What is not Other dental services not shown as covered
covered

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Triple S 2000
Vision care
What is covered In addition to medical and surgical benefits provided for diagnosis and treatment of diseases of the eye
annual eye refractions that include the written lens prescription may be obtained from Plan providers
You pay a 10 copay per office visit

What is not Eye exercises
covered Corrective lenses eyeglasses frames contact lenses fitting of contact lenses

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Triple S 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 or eligible self referred
services

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

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Triple S 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 Medicare Choice plan and also remain enrolled
with us

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

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

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

For information on Medicare Choice plans contact your local Social Security Administration SSA office
or request it from SSA at 1 800 638 6833

Other group insurance When anyone has coverage with us and with another group health plan it is called double coverage You
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

Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to provide
beyond 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 another
responsible for person caused you must reimburse us for whatever services we paid for We will cover the cost of treatment
injuries 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

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Triple S 2000
Workers We do not cover services that
compensation You need because of a workplace related disease or injury that the Office of Workers Compensation

Programs OWCP or a similar Federal or State agency determine they must provide
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding
that is based on a claim you filed under OWCP or similar laws

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

Medicaid We pay first if both Medicaid and this Plan cover you

Other Government We do not cover services and supplies that a local State or Federal Government agency directly or
Agencies indirectly pays for

If you have a If you have a malpractice claim because of services you did or did not receive from a plan provider it must
malpractice claim go to binding arbitration Contact us about how to begin our binding arbitration process

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Triple S 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 right to
information about information about your health plan its networks providers and facilities You can also find out about care
your HMO 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 787 749 4777 or write to P O Box 363628 San Juan P R
00936 3628 You may also contact us by fax at 787 749 4108 or visit our website at http www ssspr com
or by e mail at FEDINFO ssspr com

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 an
enrolling in the 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 don't determine who is eligible for coverage and in most cases cannot change your enrollment status
without information from your employing or retirement office

When are my The benefits in this brochure are effective on January 1 If you are new to this plan your coverage and
benefits and premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants
premiums effective 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 the
I retire FEHB Program for the last five years of your Federal service If you do not meet this requirement you may be eligible for other forms of coverage such as Temporary Continuation of Coverage which is described

later in this section

What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and your unmarried
coverage are dependent children under age 22 including any foster or step children your employing or retirement office
available for my authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22
family and me 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

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Triple S 2000
Are my medical and We will keep your medical and claims information confidential Only the following will have access to it
claims records
confidential OPM this Plan and subcontractors when they administer this contract 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 We will send you an Identification ID card Use your copy of the Health Benefits Election Form
cards SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You can also use
an Employee Express confirmation letter

What if I paid a Your old plan's deductible continues until our coverage begins
deductible under
my old plan

Pre existing We will not refuse to cover the treatment of a condition that you or a family member had before you
conditions enrolled in this Plan solely because you had the condition before you enrolled

When you lose
benefits

What happens if You will receive an additional 31 days of coverage for no additional premium when
my enrollment in
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

What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits under your
spouse coverage former spouse 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

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Triple S 2000
How do I enroll in If you leave Federal service your employing office will notify you of your right to enroll under TCC You
TCC must enroll within 60 days of leaving or receiving this notice whichever is later

Children You must notify your employing or retirement office within 60 days after your child is no longer
an eligible family member That office will send you information about enrolling in TCC You must enroll
your child within 60 days after 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 You may convert to an individual policy if
to individual
coverage Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not pay
your premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law

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

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

How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that indicates
Certificate of how long you have been enrolled with us You can use this certificate when getting health insurance
Group Health or other health care coverage You must arrange for the other coverage within 63 days of leaving this Plan
Plan Coverage 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

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Triple S 2000
Department of Defense FEHB Demonstration Project

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

Who is Eligible DoD determines who is eligible to enroll in FEHB Generally you may enroll if
You are an active or retired uniformed service member and are eligible for Medicare
You are a dependent of an active or retired uniformed service member and are eligible for Medicare
You are a qualified former spouse of an active or retired uniformed service member and you have not
remarried or
You are a survivor dependent of a deceased active or retired uniformed service member and
You live in one of the eight geographic demonstration areas

If you are eligible to enroll in a plan under the regular Federal Employees Health benefits Program you are
not eligible to enroll under the DoD FEHBP Demonstration Project

Where are the Dover AFB DE
demonstration Commonwealth of Puerto Rico
areas Fort Knox KY Greensboro Winston Salem High Point NC

Dallas TX
Humboldt County CA area
Naval Hospital Camp Pendleton CA
New Orleans LA

When Can I Join Your first opportunity to enroll will be during the 1999 Open Season november 8 1999 through December 13 1999 Your coverage will begin january 1 2000 DoD has set up an Information Processing Center
IPC in Iowa to provide you with information about how to enroll IPC staff will verify your eligibility and
provide you with FEHB Program information plan brochures enrollment instructions and forms The tollfree
phone number for IPC is 1 877 DOD FEHB 1 877 363 3342

You may select coverage for yourself self only or for you and your family self and family during the
1999 2000 and 2001 Open Seasons Your coverage will begin January 1 of the year following the Open
Season that you enrolled

If you become eligible for the DoD FEHBP Demonstration Project outside of Open Season contact the IPC
to find out how to enroll and when your coverage will begin

DoD has a web site devoted to the demonstration Project You can view information such as their Marketing
Beneficiary Education Plan Frequently Asked Questions demonstration area locations and zip code
lists at www tricare osd mil fehbp You can also view information about the demonstration project including
The 2000 Guide to Federal Employees Health Benefits Plans Participating in the DoD FEHBP Demonstration
Project on the OPM web site at www opm gov

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Triple S 2000
Am I eligible for See Section 10 FEHB Facts for information about TCC Under this Demonstration Project the only individual
Temporary eligible for TCC is one who ceases to be eligible as a member of family under your self and family
Continuation of enrollment This occurs when a child turns 22 for example or if you divorce and your spouse does not
Coverage TCC qualify to enroll as an unremarried former spouse under title 10 United States Code For these individuals TCC begins the day after their enrollment in the DoD FEHBP Demonstration Project ends TCC enrollment

terminates after 36 months or the end of the Demonstration Project whichever occurs first You your
child or another person must notify the IPC when a family member loses eligibility for coverage under the
DoD FEHBP Demonstration Project

TCC is not available if you move out of a DoD FEHBP Demonstration Project area you cancel your coverage
or your coverage is terminated for any reason TCC is not available when the demonstration project
ends

Do I have the 31 Day These provisions do not apply to the DoD FEHBP Demonstration Project
Extension and Right
to Convert

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Triple S 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 787 749 4777 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 this Plan and try to obtain benefits

Your agency may also take administrative action against you

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Triple S 2000
Summary of Benefits for Triple S 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

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 if medically necessary diagnostic tests drugs and medical
supplies use of operating room intensive care and complete maternity care
You pay nothing 13

Extended Care All necessary services no dollar or day limit You pay nothing 13
Mental Conditions Up to 90 days of inpatient care per calendar year Two days of partial
hospitalization are equivalent to one full day of hospitalization You pay
nothing per admission to a participating hospital 15

Substance Abuse Covered under Mental Conditions Benefits 16

Outpatient care Comprehensive range of services such as diagnosis and treatment of illness or injury including specialist's care preventive care including well baby care
periodic check ups and routine immunizations laboratory tests and X rays
complete maternity care You pay a 7.50 copay per office visit to a Plan doctor
general practitioner and 10 copay per office visit to a Plan doctor specialist
copay is waived for maternity care and 15 per doctor's home visit 10 13

Home Health Care All necessary visits by nurses and health aides You pay nothing 11
Mental Conditions Up to 40 outpatient visits per year You pay a 5 copay per visit for visits 1 20
and 50 of charges for visits 21 40 15

Substance Abuse Covered under Mental Conditions Benefits 16
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 5 copay to the hospital for each emergency room visit
and any charges for services that are not covered benefits of this Plan If you
call the toll free number before reaching emergency room or urgent care center
and receive an authorization you pay nothing 14

Prescription drugs Prescribed drugs provided by a Plan pharmacy You pay 20 coinsurance up to a maximum of 10 per brand name prescription unit or refill or nothing per
generic bioequivalent prescription unit or refill 17

Dental care Accidental injury benefits oral examinations fluoride treatments prophylaxis x rays extractions and fillings You pay a percentage of charges as shown 18

Vision care Refractions You pay 10 per visit 19
Out of pocket Your out of pocket expenses for benefits covered under this Plan are limited to
maximum the stated copayments which are required for benefits when Plan providers are used 5

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Triple S 2000 2000 Rate Information for
Triple S Inc

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

All of Puerto Rico
Self Only 891 63.89 21.30 138.44 46.14 75.61 9.58 75.61 9.58
Self and Family 892 137.22 45.74 297.31 99.10 162.38 20.58 162.38 20.58 31

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