Pages 1--24 from 2000 UHS BODY

Serving Chicago Area For changes in benefits
page 2 see
Enrollment in this Plan is limited see page 3 for requirements

Enrollment code
761 Self Only
762 Self and Family

Visit the OPM website at http www opm gov insure
Authorized for distribution by the
United States Office of
Personnel Management
Retirement and Insurance Service

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Union Health Service 2000
Table of Contents
Introduction .1
Plain language .1
How to use this brochure .1
Section 1 Health Maintenance Organizations .2
Section 2 How we change for 2000 .2
Section 3 How to get benefits .3
Section 4 What to do if we deny your claim or request for service .5
Section 5 Benefits .7
Section 6 General exclusions Things we don't cover .15
Section 7 Limitations Rules that affect your benefits .16
Section 8 FEHB Facts .17
Inspector General Advisory Stop Healthcare Fraud .20
Summary of benefits Inside Back Cover
Premiums Back Cover

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Union Health Service 2000
Introduction
Union Health Service 1634 West Polk Street Chicago Illinois 60612
This brochure describes the benefits you can receive from Union Health Service under its contract CS1571 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 2 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 Union Health Service 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

How To Use This Brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make comparisons
easier
1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and how they work

2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not to pay for your claim or to deny your request for a service

5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find information about non FEHB benefits
6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB facts Read this for information about the Federal Employees Health Benefits FEHB Program

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Union Health Service 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and other providers that contract with us These providers coordinate your health care services The care you receive includes preventative
care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury
When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay copayments and coinsurance listed in this brochure When you receive emergency services you may have to submit claim forms

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

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

This year you have a right to more information about this Plan care management our networks facilities and providers
If you have a chronic or disabling condition and your provider leaves the Plan at our request you may continue to see your specialist for up to 90 days If your provider leaves the Plan and you are
in the second or third trimester of pregnancy you may be able to continue seeing your OB GYN until the end of your postpartum care You have similar rights if this Plan leaves the FEHB program
See Section 3 How to get benefits for more information
You may review and obtain copies of your medical records on request If you want copies of your medical records ask your health care provider for them You may ask that a physician amend a
record that is not accurate not relevant or incomplete If the physician does not amend your record you may add a brief statement to it If they do not provide you your records call us and we will
assist you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This screening is for colorectal cancer

Changes to this Your share of the non postal premium will increase by 3.7 for Self Only or 4.2 for Self and Plan Family
We have clarified the Prescription Drug Benefit to show that we cover oral and injectable contraceptive drugs and devices

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Union Health Service 2000
Section 3 How to get benefits
What is this To enroll with us you must live or work in our service area This is where our providers practice Plan's service Our service area is The Chicago Area located in Cook and DuPage counties Illinois
area 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
If you or a covered family member move outside of our service area you can enroll in another plan If your dependents live out of the area for example if your child goes to college in another state
you should consider enrolling in a fee for service plan or an HMO that has agreements with affiliates in other areas If you or a family member move you do not have to wait until Open
Season to change plans Contact your employing or retirement office

How much do Your out of pocket expenses for benefits covered under this Plan are limited to the stated copay I pay for ments required for a few benefits
services

Do I have to You normally won't have to submit claims to us unless you receive emergency services from a submit claims provider who doesn't contract with us If you file a claim please send us all of the documents for
your claim as soon as possible You must submit claims by December 31 of the year after the year you received the service Either OPM or we can extend this deadline if you show that circumstances
beyond your control prevented you from filing on time

Who provides UHS is a Staff Model Group Practice Plan that employs its doctors All doctors are either Board my health certified or eligible in their specialties and are affiliated with some of the area's finest hospitals
care

Who Whatprovides do I do if Call us We will help you select a new one my my primary health
care care physician leaves the Plan

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

What do I do if First call our Utilization Management Department at 312 829 4224 If you are new to the FEHB I'm in the Program we will arrange for you to receive care If you are currently in the FEHB Program and
hospital when are switching to us your former plan will pay for the hospital stay until I join this
Plan 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

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Union Health Service 2000
Section 3 How to get benefits continued
How do I get Your primary care physician will arrange your referral to a specialist with the following exception specialty care a woman may see her Plan obstetrician gynecologist directly with no need to be referred by her
primary care doctor if specialists are required beyond those participating in the Plan the primary care physician will arrange for appropriate referrals

Our Medical Director must approve your referral to an outside specialist before you receive treatment When you receive a referral from your primary care physician to an outside specialist you
must return to the primary care physician after the consultation Your primary care physician must provide or authorize all follow up care On outside referrals your primary care physician will give
specific instructions to the specialist as to what services are authorized If the specialist suggests additional services or visits you must check with your primary care physician for approval and
authorization Do not go to the outside specialist unless your primary care physician has arranged for and the Plan has issued an authorization for the referral in advance

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

What do I do Your primary care physician will decide what treatment you need If they decide to refer you to a if I am seeing a specialist ask if you can see your current specialist If your current specialist does not participate
specialist when with us you must receive treatment from a specialist who does Generally we will not pay for you I enroll to see a specialist who does not participate with our Plan

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

But what if I have Please contact us if you believe your condition is chronic or disabling You may be able to continue a serious illness seeing your provider for up to 90 days after we notify you that we are terminating our contract with
and my provider the provider unless the termination is for cause If you are in the second or third trimester of leaves the Plan or pregnancy you may continue to see your OB GYN until the end of your postpartum care
this Plan 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 referring you to a specialist authorize or recommending follow up care Before giving approval we consider if the service is medically
medical services necessary and if it follows generally accepted medical practice

How do you If a medical treatment procedure drug device or biological product is FDA approved the Plan decide if a service will use this as a basis for providing coverage If it lacks FDA's approval the Plan will make a
is experimental or policy decision based on specific statements from specialty societies or medical organizations such investigational as the American Cancer Society the American College of Surgeons and the American Medical
Association
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Union Health Service 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

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

What if I have Call us 312 829 4224 and we will expedite our review a serious or life
threatening condition and you
haven't 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 inform denied my request OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's
for care and my health benefits Contract Division 3 at 202 606 0755 between 8 a m and 5 p m 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 You must write to OPM and ask them to review our decision within 90 days after we uphold our time limits initial denial or refusal of service You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your request within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30 days In this case OPM must receive your request within 120 days of the date we asked you
for additional information

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Union Health Service 2000
Section 4 What to do if we deny your claim or request for service continued
What do I send Your request must be complete or OPM will return it to you You must send the following to OPM information

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

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

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

the review request

Where should I Send your request for review to Office of Personnel Management Office of Insurance Programs mail my disputed Contract Division 3 P O Box 436 Washington D C 20044
claim to OPM

What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our upholds the decision your only recourse is to sue
Plan's 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 Federal law governs your lawsuit benefits and payment of benefits The Federal court will base if I file a its review on the record that was before OPM when OPM made its decision on your claim You
lawsuit 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 the Privacy Act and us to determine if our denial of your claim is correct The information OPM collects during the
review process becomes a permanent part of your disputed claim file and is subject to the provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this information
to support the disputed claim decision If you file a lawsuit this information will become part of the court record

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Union Health Service 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 10.00 per office
visit Within the service area house calls will be provided if in the judgment of the Plan doctor such care is necessary and appropriate you pay a 10.00 copay for a doctor's house call and

nothing for home visits by 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
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor 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 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
Infertility services diagnosis and treatment including artificial insemination The following types of artificial insemination are covered intravaginal insemination IVI intracervical

insemination ICI and intrauterine insemination IUI Fertility drugs are covered as mandated by the State of Illinois

Other assisted reproductive technology ART procedures that enable a woman with otherwise untreatable infertility to become pregnant through other artificial conception procedures such
as in vitro fertilization and embryo transfers including medical examinations in accordance with the limitations specified in the State of Illinois mandated benefits

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 The implanted device is provided at 80 of actual charges subject to a 100 deductible per member

per calendar year maximum 300 family deductible you pay 20 of charges after deductible is met

Cornea heart kidney 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 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

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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Union Health Service 2000
Section 5 Benefits continued
What is covered Home health services of nurses and health aides including intravenous fluids and medications con't when prescribed by your Plan doctor who will periodically review the program for continuing
appropriateness and need
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers at no additional cost to you

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 including shortening of the mandible or maxillae for cosmetic purposes correction of malocclusion and any dental care involved in treatment of
temporomandibular joint TMJ pain dysfunction syndrome
Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from an injury or surgery that has produced a major effect on the member's appearance and if the
condition can reasonably be expected to be corrected by such surgery A patient and her attending physician may decide whether to have breast reconstruction surgery following a mastectomy and
whether surgery on the other breast is needed to produce a symmetrical appearance
Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis for up to 60 treatments per condition per calendar year if significant improvement
can be expected within two months 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

Cardiac rehabilitation following a heart transplant bypass surgery or myocardial infarction is provided for up to 30 days you pay nothing
Durable medical equipment orthopedic and prosthetic devices Benefits are provided for the purchase or rental up to the purchase price of medically necessary equipment including hospital
beds wheelchairs braces foot orthotics artificial limbs eyes and lenses following cataract removal and breast prostheses and surgical bras as well as their replacement The benefit is
provided at 80 of actual charges subject to a 100 deductible per member per calendar year maximum 300 family deductible you pay 20 of charges after deductible is met

What is not Physical examinations that are not necessary for medical reasons such as those required for covered 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
Hearing aids
Long term rehabilitative therapy
Homemaker services
Chiropractic services
Donor sperm

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Union Health Service 2000
Hospital Extended Care Benefits
What is covered
Hospital Care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan doctor You pay nothing All necessary services are covered
including
Semiprivate room accommodations when a Plan doctor determines it is medically necessary the doctor may prescribe private accommodations or private duty nursing care

Specialized care units such as intensive care or cardiac care units

Extended Care The Plan provides a comprehensive range of benefits for up to 60 days per calendar year when fulltime skilled nursing care is necessary and confinement in a skilled nursing facility is medically
appropriate as determined by a Plan doctor and approved by the Plan You pay nothing All necessary services are covered including

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

Hospice care Supportive and palliative care for a terminally ill member is covered in the home or hospice facility Services include inpatient and outpatient care and family counseling these services are provided
under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness with a life expectancy of approximately six months or less

Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a procedures 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 Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis detoxification treatment of medical conditions and medical management of withdrawal symptoms acute detoxification
if the Plan doctor determines that outpatient management is not medically appropriate See page 12 for nonmedical substance abuse benefits

What is not Personal comfort items such as telephone and television covered
Custodial care rest cures domiciliary or convalescent care

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Union Health Service 2000
Emergency Benefits
What is a A medical emergency is the sudden and unexpected onset of a condition or an injury that you medical believe endangers your life or could result in serious injury or disability and requires immediate
emergency medical or surgical care Some problems are emergencies because if not treated promptly they might become more serious examples include deep cuts and broken bones Others are emergencies
because they are potentially life threatening such as heart attacks strokes poisonings gunshot wounds or sudden inability to breathe There are many other acute conditions that the Plan

may determine are medical emergencies what they all have in common is the need for quick action

Emergencies If you are in an emergency situation please call the Plan 24 hour emergency number at once at within the 312 829 4224 The Plan has doctors on call around the clock seven days a week In extreme
service area emergencies if you are unable to contact your doctor contact the local emergency system e g the 911 telephone system or go to the nearest hospital emergency room 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 must notify the Plan within 48 hours unless it was not reasonably possible to do so It is your

responsibility to ensure that the Plan has been timely notified
If you need to be hospitalized in a non Plan facility the Plan must be notified within 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 non Plan 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 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 Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 25 per hospital emergency room visit or urgent care center visit for emergency services that are covered benefits of this Plan
Emergencies Benefits are available for any medically necessary health service that is immediately required outside the because of injury or unforeseen illness
service area 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 transferred

when medically feasible with any ambulance charges covered in full

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

You pay 25 per hospital emergency room visit or urgent care center visit for emergency services that are covered benefits of this Plan

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Union Health Service 2000
Emergency Benefits continued
What is covered Emergency care at a doctor's office or an urgent care center
Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service approved by the Plan

What is not Elective care or nonemergency care covered
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

Filing claims With your authorization the Plan will pay benefits directly to the providers of your emergency care for non Plan upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form
providers If you are required to pay for the services submit itemized bills and your receipts to the Plan along with an explanation of the services and the identification information from your ID card Payment
will be sent to you or the provider if you did not pay the bill unless the claim is denied If it is denied you will receive notice of the decision including the reasons for the denial and the provisions

of the contract on which denial was based If you disagree with the Plan's decision you may request reconsideration in accordance with the disputed claims procedure described on page 5

Mental Conditions Substance Abuse Benefits
Mental For services contact the Plan at 312 829 4224 conditions

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 disorders
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 calendar year you pay nothing per visit for up to 20 visits all charges thereafter

Inpatient care Up to 30 days of hospitalization each calendar year you pay nothing for first 30 days all charges thereafter
What is not covered Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to 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 that is not medically necessary to determine the appropriate treatment of a short term psychiatric condition

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Union Health Service 2000
Mental Conditions Substance Abuse Benefits continued
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 and to the extent shown below the services necessary for diagnosis and treatment

Outpatient care Up to 20 visits to Plan providers for treatment each calendar year you pay nothing per visit for up to 20 visits all charges thereafter
Inpatient care Inpatient care for substance abuse is limited to up to 30 days in either an alcohol detoxification or rehabilitation center approved by the Plan you pay nothing for the first 30 days all charges
thereafter

What is not covered Treatment that is not authorized by a Plan doctor
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 30 day supply or 100 unit supply whichever is less 240 milliliters of liquid
8 oz 60 grams of ointment creams or topical preparation or one commercially prepared unit i e one inhaler one vial ophthalmic medication or insulin You pay a 5 copay per prescription

unit or refill generic drugs will be dispensed when available
Covered medications and accessories include
Drugs for which a prescription is required by law
Insulin
Insulin syringes and needles
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

Fertility drugs are covered under infertility benefits see page 7
Oral and injectable contraceptive drugs and devices

Limited Benefits Sexual dysfunction drugs have dispensing limitations Contact the Plan for details
What is not Drugs available without a prescription or for which there is a nonprescription equivalent covered available
Drugs obtained at a non Plan pharmacy except for out of area 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
Smoking cessation drugs and medication including nicotine patches

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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Union Health Service 2000
Other Benefits
Dental care

Accidental injury Restorative services and supplies necessary to promptly repair but not replace sound natural teeth benefit are covered The need for these services must result from an accidental injury You pay nothing

Vision care
What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye one annual eye refraction which includes the written lens prescription may be obtained

from Plan providers You pay nothing

What is not covered Corrective lenses or frames
Eye exercises

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Union Health Service 2000
Non FEHB Benefits Available to Plan Members The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made available
to all enrollees and family members of this Plan The cost of the benefits described on this page is not included in the FEHB premium and any charges for these services do not count toward any FEHB deductibles or out of pocket maximums These benefits are
not subject to the FEHB disputed claims procedure
Vision care One annual eye refraction which includes the written lens prescription may be obtained by a UHS optometrist The services are available by appointment at the UHS Eye Care Center 312 829
4224 located at the UHS Main Facility 1634 West Polk Street Chicago IL 60612
UHS Plan members receive special package prices and discounts on eyeglasses frames lenses and optical accessories at all For Eyes Optical store locations

For further information about our Vision Benefits please contact our Customer Service Department at 312 829 4224

Dental care Dental Services are available to UHS Plan Members The services are available by appointment at the UHS Dental Office 312 829 4224 located at the UHS Main Facility 1634 West Polk Street
Chicago IL 60612
Annual Office Visit No charge
Annual Oral Examination and diagnosis No charge
Annual Fluoride Treatment No charge dependent under age 19

Other dental services are available at reduced cost with an additional 20 discount Payment is required at the time of service

These benefits are available only at the UHS Dental Office Union Health Service 2nd Floor 1634 West Polk Street Chicago IL 60612
For further information about our Dental Benefits please contact our Marketing Department at 312 829 4224

Benefits on this page are not part of the FEHB contract

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Union Health Service 2000
Section 6 General Exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition

We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest

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

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Union Health Service 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 re enroll in the FEHB Program generally you may do so only at the next Open
Season
If you involuntarily lose coverage or move out of the Medicare Choice service area you may re enroll in the FEHB Program at any time

If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration SSA office or request it from SSA at 1 800 638 6833

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

National Association of Insurance Commissioners Guidelines
If we pay second we will determine 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 our control provide them In that case we will make all reasonable efforts to provide you with necessary care
When others are When you receive money to compensate you for medical or hospital care for injuries or illness that responsible for another person caused you must reimburse us for whatever services we paid for We will cover the
injuries cost of treatment that exceeds the amount you received in the settlement If you do not seek damages you must agree to let us try This is called subrogation If you need more information
contact us for our subrogation procedures

TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you
we are the primary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE coverage

Workers 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 Agencies or indirectly pays for

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Union Health Service 2000
Section 8 FEHB Facts
You have a right OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the to information right to information about your health plan its networks providers and facilities You can also find
about your out about care management which includes medical practice guidelines disease management HMO 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 our Member Advocate at 312 829 4224 or write to Union Health Service 1634 West Polk Street Chicago Illinois 60612

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 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 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 you retire you can usually stay in the FEHB Program Generally you must have been when I retire enrolled in the FEHB Program for the last five years of your Federal service If you do not meet
this requirement you may be eligible for other forms of coverage such as Temporary Continuation of Coverage which is described later in this section

What types of Self Only 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

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Union Health Service 2000
Section 8 FEHB Facts continued
Are my medical We will keep your medical and claims information confidential Only the following will have and 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 subrogating claims

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

OPM when reviewing a disputed claim or defending litigation about a claim

Information for new members
Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form 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 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 spouse's enrollment But you may be eligible for your own FEHB coverage
under the spouse equity law If you are recently divorced or are anticipating a divorce contact your ex spouse's employing or retirement office to get more information about your coverage choices

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

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

You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
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Union Health Service 2000
Section 8 FEHB Facts continued
How do I If you leave Federal service your employing office will notify you of your right to enroll under enroll in 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 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 You may convert to an individual policy if convert to
Your coverage under TCC or the spouse equity law ends If you canceled your coverage or individual coverage 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 If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that a Certificate of indicates how long you have been enrolled with us You can use this certificate when getting health
Group Health insurance or other health care coverage You must arrange for the other coverage within 63 days of Plan Coverage 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

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Union Health Service 2000
Inspector General Advisory Stop Healthcare 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 312 829 4224 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 If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that Fraud indicates how long you have been enrolled with us You can use this certificate when getting health
insurance or other health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions
for health related conditions based on the information in the certificate
Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud Also the Inspector General may investigate anyone who uses an ID card if they

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

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Union Health Service 2000
Summary of Benefits for Union Health Service 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 PHYSICIANS

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

and private nursing care if medically necessary diagnostic tests drugs and medical supplies use of operating room intensive care and complete maternity care
You pay nothing .7
Extended care All necessary services up to 60 days per calendar year You pay nothing .9
Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient conditions care per year You pay nothing .11

Substance Up to 30 days per year in a substance abuse treatment program You pay nothing .12 abuse

Outpatient Comprehensive range of services such as diagnosis and treatment of illness or injury care 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 10 copay per office visit 10 per house call by a physician .7 8

Home health All necessary visits by nurses and health aides You pay nothing .8 care
Mental Up to 20 outpatient visits per year You pay nothing .11 conditions
Substance Up to 20 outpatient visits per year You pay nothing .12 abuse

Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay 25 copay to the hospital for each emergency room visit and any charges for
services that are not covered by this Plan .10

Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5 copay per prescription unit or refill .12

Dental care Accidental injury benefit You pay nothing .13
Vision care One refraction annually You pay nothing .13
Out of pocket maximum Your out of pocket expenses for benefits covered under this Plan are limited to the stated copayments which are required for a few benefits .3 23
23 Page 24
Authorized for distribution by the
United States Office of
Personnel Management

2000 Rate Information for Union Health Service

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

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

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

Self Only 761 62.31 20.77 135.01 45.00 73.73 9.35 73.73 9.35
Self and Family 762 155.18 51.73 336.23 112.08 183.63 23.28 183.63 23.28 24

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