A Health Maintenance Organization
For changes benefits 5
in
see page
Serving Most of Colorado
Enrollment in this Plan is limited see page 8 for requirements
Enrollment code
881 Self Only
882 Self and Family
Rocky Mountain HMO has NCQA
Commendable Accreditation effective through
March 27 2000 See the 2000 Guide
for more information on NCQA
Visit the OPM website at http www opm gov insure
and
our website at http www rmhmo org
Authorized for distribution by the
United States
Office of
Personnel
Management RI 73 027
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Rocky Mountain HMO 2000
Table of Contents
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 16
Section 6 General exclusions Things we don't cover 17
Section 7 Limitations Rules that affect your benefits 17
Section 8 FEHB FACTS 18
Information for new members 19
When you lose benefits 20
Inspector General Advisory Stop Health Care Fraud 22
Summary of Benefits for Rocky Mountain HMO 2000 23
2000 Rate Information for Rocky Mountain HMO Back cover
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Rocky Mountain HMO 2000
Introduction
Rocky Mountain HMO 2275 Crossroads Boulevard Grand Junction CO 81506
This brochure describes the benefits you can receive from Rocky Mountain HMO under its contract CS1662 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 11
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 Rocky Mountain HMO 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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Rocky Mountain HMO 2000
How to use this brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits
with benefits from other FEHB plans you will find that the brochures have the same format and similar information to make
comparisons easier
1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and how
they work
2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not to
pay for your claim or to deny your request for a service
5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find
information about non FEHB benefits
6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB FACTS Read this for information about the Federal Employees Health Benefits FEHB Program
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Rocky Mountain HMO 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 Plan Your share of the premium will decrease by 31.0 for Self Only or 35.1 for Self and Family
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Section 3 How to get benefits
What is this To enroll with us you must live or work in the Rocky Mountain HMO service area This is where
Plan's service our providers practice Our service area is
area Adams El Paso Montrose
Alamosa Fremont Ouray
Archuleta Garfield Park
Arapahoe Gilpin Pitkin
Boulder Hinsdale Pueblo
Cheyenne Jefferson Rio Grande
Clear Creek Kiowa Rio Blanco
Conejos Kit Carson Saguache
Costilla Lake San Miguel
Custer La Plata San Juan
Delta Lincoln Summit
Denver Logan Teller
Dolores Mesa Washington
Douglas Mineral Yuma
Eagle Moffat
Elbert Montezuma
Ordinarily you must get your care from providers who contract with us If you receive care outside
our service area we will pay only for emergency care We will not pay for any other health care
services
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 I pay for You must share the cost of some services This is called either a copayment a set dollar amount or
services coinsurance a set percentage of charges Please remember you are not required to pay any applicable copayments to the physician or hospital at the time of service You will receive a
statement from the plan if you are responsible for copayments
After you pay 750 in copayments or coinsurance for one family member or 1,500 for two or
more family members you do not have to make any further payments for certain services for the
rest of the year This is called a catastrophic limit However copayments or coinsurance for your
prescription drugs and dental services do not count toward these limits and you must continue to
make these payments
Be sure to keep accurate records of your copayments and coinsurance since you are responsible
for informing us when you reach the limits
Do I have to You normally won't have to submit claims to us unless you receive emergency services from a
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
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Rocky Mountain HMO 2000
Who provides my Rocky Mountain HMO is an individual practice prepayment plan that contracts with hospitals and
health care health care professionals throughout Colorado
The first and most important decision each member must make is the selection of a primary car
doctor The decision is important since it is through this doctor that all other health services
particularly those of specialists are coordinated It is the responsibility of your primary care doctor
to obtain any necessary authorization from the Plan before referring you to a specialist or making
arrangements for hospitalization Services of other providers are covered only when there has been
a referral by the member's primary care doctor with the following exception a woman may see
her Plan gynecologist for her annual routine examination without a referral
What do I do if my primary Call us We will help you select a new one
care physician leaves the
Plan
What do I do if I need to Talk to your Plan physician If you need to be hospitalized your primary care physician or
go into the hospital specialist will make the necessary hospital arrangements and supervise your care
What do I do if I'm in the First call our customer service department at 970 243 7050 or 1 800 346 4643 If you are new to
hospital when I join this the FEHB Program we will arrange for you to receive care If you are currently in the FEHB
Plan Program and are switching to us your former plan will pay for the hospital stay until
You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do I get specialty Your primary care physician will arrange your referral to a specialist
care If you need to see a specialist frequently because of a chronic complex or serious medical
condition your primary care physician will develop a treatment plan that allows you to see your
specialist for a certain number of visits without additional referrals Your primary care physician
will use our criteria when creating your treatment plan The physician may have to get an
authorization or approval beforehand
What do I do if I am Your primary care physician will decide what treatment you need If they decide to refer you to a
seeing a specialist when I specialist ask if you can see your current specialist If your current specialist does not participate
enroll with us you must receive treatment from a specialist who does Generally we will not pay for you to see a specialist who does not participate with our Plan
What do I do if my Call your primary care physician who will arrange for you to see another specialist You may
specialist leaves the Plan receive services from your current specialist until we can make arrangements for you to see someone else
But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to continue
serious illness and my seeing your provider for up to 90 days after we notify you that we are terminating our contract with
provider leaves the Plan the provider unless the termination is for cause If you are in the second or third trimester of
or this Plan leaves the pregnancy you may continue to see your OB GYN until the end of your postpartum care
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
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FEHB Program If you are in your second or third trimester your new plan will pay for the OB
GYN care you receive from your current provider until the end of your postpartum care
How do you authorize Your physician must get our approval before sending you to a hospital referring you to a specialist
medical services or recommending follow up care Before giving approval we consider if the service is medically necessary and if it follows generally accepted medical practice
How do you decide if a The plan will determine the experimental investigational nature of a service supply or drug
service is experimental or through its Medical Department and Medical Director The plan in its discretion may review
investigational material from or seek input from the following groups The Food and Drug Administration The National Institutes of Health and the American Medical Association The Plan may also consider
any local community standard with respect to each service in question and inquire as to the
coverage of such service by group health insurance companies and other health maintenance
organizations in the Plan's service area
Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you
were unable to make a timely request due to reasons beyond your control
We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30 days
after we receive the additional information If we do not receive the requested information within 60 days we will make our decision
based on the information we already have
When may I ask OPM to You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal
review a denial OPM will determine if we correctly applied the terms of our contract when we denied your claim or request for service
What if I have a serious or Call us at 970 243 7050 or 1 800 346 4643 and we will expedite our review
life threatening condition
and you haven't responded
to my request for service
What if you have denied If we expedite your review due to a serious medical condition and deny your claim we will inform
my request for care and OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's
my condition is serious or health benefits Division IV at 202 606 0737 between 8 a m and 5 p m Serious or lifethreatening
life threatening conditions are ones that may cause permanent loss of bodily functions or death if they are not treated as soon as possible
Are there other time You must write to OPM and ask them to review our decision within 90 days after we uphold our
limits initial denial or refusal of service You may also ask OPM to review your claim if
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
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2 You provided us with additional information we asked for and we did not answer within 30
days In this case OPM must receive your request within 120 days of the date we asked you
for additional information
What do I send to OPM Your request must be complete or OPM will return it to you You must send the following information
1 A statement about why you believe our decision is wrong based on specific benefit provisions
in this brochure
2 Copies of documents that support your claim such as physicians letters operative reports
bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to
which claim
Who can make the Those who have a legal right to file a disputed claim with OPM are
request 1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled
person's representative They must send a copy of the person's specific written consent with
the review request
Where should I mail my Send your request for review to Office of Personnel Management Office of Insurance Programs
disputed claim to OPM Contract Division IV P O Box 436 Washington D C 20044
What if OPM upholds the OPM's decision is final There are no other administrative appeals If OPM agrees with our
Plan's denial decision your only recourse is to sue
If you decide to sue you must file the suit against OPM in Federal court by December 31 of the
third year after the year in which you received the disputed services or supplies
What laws apply if I file a Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its
lawsuit review on the record that was before OPM when OPM made its decision on your claim You may recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment
services supplies or drugs covered by us until you have completed the OPM review procedure
described above
Your records and the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you
Privacy Act and us to determine if our denial of your claim is correct The information OPM collects during the review process becomes a permanent part of your disputed claims file and is subject to the
provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this
information to support the disputed claim decision If you file a lawsuit this information will
become part of the court record
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Section 5 Benefits
Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits you pay a 10 office
visit copay for diagnostic and treatment services but no additional copay for laboratory tests and
X rays 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 nothing for house calls or for home visits by
nurses and health aides
The following services are included
Preventive care to include annual physicals well child care Pap smears and prostate
screening copay waived
Mammograms for women are covered as follows for women age 35 through age 39 one
mammogram during these five years for women age 40 through age 49 one mammogram
every one or two years for women age 50 through age 64 one mammogram every year
for women age 65 and over one mammogram every two years In addition to routine
screening mammograms are covered when prescribed by a Plan doctor as medically
necessary to diagnose or treat an illness
Routine immunizations and boosters copay waived
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery
and postnatal care by a Plan doctor office visit copays are waived for obstetrical care
The mother at her option may remain in the hospital up to 48 hours after a regular
delivery and 96 hours after a cesarean delivery Inpatient stays will be extended if
medically necessary 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
Diagnosis and treatment of diseases of the eye including external lenses following cataract
removal or other eye surgery
Allergy testing and treatment including test and treatment materials such as allergy
serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart lung kidney liver single lung double lung pancreas and pancreas
kidney transplants allogeneic donor bone marrow transplants autologous bone marrow
transplants autologous stem cell and peripheral stem cell support for the following
conditions acute lymphocytic or non lymphocytic leukemia advanced Hodgkin's
lymphoma advanced non Hodgkin's lymphoma advanced neuroblastoma testicular
mediastinal retroperitoneal and ovarian germ cell tumors breast cancer multiple
myeloma and epithelial ovarian cancer Participation in non randomized clinical trials
may be required for treatment of breast cancer multiple myeloma and epithelial ovarian
cancer Coverage for all transplants will be based on Plan medical criteria Related
medical and hospital expenses of the donor are covered when the recipient is covered by
this Plan The procurement of an organ or bone marrow and private duty nursing related
to transplants are covered in full
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
External breast prosthesis and surgical bras following a mastectomy
Diabetic education provided by a Plan approved diabetic educator or education program
Nutritional counseling provided by a Plan dietician
Dialysis
Chemotherapy radiation therapy and inhalation therapy
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Surgical treatment of morbid obesity
Non routine podiatric care such as treatment of bunions ingrown toenails and hammer
toes
Durable medical equipment such as wheelchair and hospital beds on loan from the Plan
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
Hearing exams up to age 18
Home oxygen
Disposable medical supplies such as syringes needles urine testing materials and tubing
when necessary in the home treatment of insulin dependent diabetes allergic conditions
requiring injections and conditions involving home administration of parenteral
nutrition ostomy supplies and or urethral catheter supplies
Diaphragms and IUDs
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 hospitalization procedure 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 intra oral
areas surrounding the teeth are not covered including 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
Short term rehabilitative therapy physical pulmonary speech and occupational therapy is
provided on an outpatient basis for up to 20 visits or 60 consecutive days whichever is greater per
condition if significant improvement can be expected within two months Inpatient therapy is
provided for up to two months per condition You pay a 10 copay per outpatient session nothing
for inpatient 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 reconditioning program for functional restoration of post heart attack patients are
provided you pay nothing Phase III maintenance is not covered
Prosthetic devices such as artificial limbs and orthopedic devices such as braces and foot
orthotics that require a prescription you pay 50 of charges
Diagnosis and treatment of infertility is covered for up to four procedures per pregnancy
attempts you pay nothing The following types of artificial insemination are covered intravaginal
insemination IVI intracervical insemination ICI and intrauterine insemination IUI The cost
of donor sperm is not covered Other assisted reproductive technology ART procedures such
as in vitro fertilization and embryo transfer are not covered Fertility drugs are covered under the
prescription drug benefit
Enteral Nutrition up to 3 years of age for treatment of a severe gastrointestinal disorder prior
authorization by RMHMO is required
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
unless such examination is the only physical examination obtained during the calendar
year
Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Hearing aids
Chiropractic services
Homemaker services
Blood and blood derivative not replaced by the member
Transplants not specified as covered
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What is not Long term rehabilitative therapy
covered continued Radial keratotomies Cochlear implants implantation procedure is covered but not the device
Biofeedback
Hospital Extended Care Benefits
What is covered The Plan provides a comprehensive range of benefits with no dollar or day limit when you are
Hospital care 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 100 days per member per calendar year when full time skilled nursing care is necessary and confinement in a skilled nursing facility is
medically appropriate as determined by a Plan doctor and approved by the Plan You pay nothing
All necessary services are covered including
Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled
nursing facility when prescribed by a Plan doctor
Hospice care Supportive and palliative care for a terminally ill member is covered in the home or hospice facility A maximum of ten 10 days of respite care are provided 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 Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a
Inpatient dental need for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover
procedures 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 detoxification if the Plan doctor determines that outpatient management is not medically
appropriate See page 14 for nonmedical substance abuse benefits
What is not covered Personal comfort items such as telephone and television Blood and blood derivatives not replaced by the member
Custodial care rest cures domiciliary or convalescent care
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you
emergency believe endangers your life or could result in serious injury of disability and requires immediate medical or surgical care Some problems are emergencies because if not treated promptly they
might become more serious examples include deep cuts and broken bones Others are emergencies
because they are potentially life threatening such as heart attacks strokes poisonings gunshot
wounds or sudden inability to breathe There are many other acute conditions that the Plan may
determine are medical emergencies C what they all have in common is the need for quick action
Emergencies within the If you are in an emergency situation please call your primary care doctor In extreme emergencies
service area 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
should notify the Plan within 72 hours It is your responsibility to ensure that the Plan has been
timely notified
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If you need to be hospitalized the Plan must be notified within 72 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 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
To be covered by this Plan any follow up care recommended by non Plan providers must be
approved by the Plan or provided by Plan providers
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 50 per hospital emergency room visit or urgent care center visit for emergency services that are
covered benefits of this Plan If the emergency results in admission to a hospital the emergency
care copay is waived
Emergencies outside the Benefits are available for any medically necessary health service that is immediately required
service area because of injury or unforeseen illness
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day
following your admission unless it was not reasonably possible to notify the Plan within that time
If a Plan doctor believes care can be better provided in a Plan hospital you will be transferred
when medically feasible with any ambulance charges covered in full
To be covered by this Plan any follow up care recommended by non Plan providers must be
approved by the Plan or provided by Plan providers
Plan pays Reasonable charges for emergency care services to the extent the services would have been covered if received from Plan providers
Follow up care resulting from an injury or unforeseen illness is covered up to a maximum Plan
payment of 250
You pay 50 per hospital emergency room visit or urgent care center visit for emergency services that are
covered benefits of this Plan If the emergency results in admission to a hospital the emergency
care copay is waived You pay 50 of charges for follow up care up to a maximum Plan payment
of 250 all charges thereafter
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 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
Filing claims for non plan With your authorization the Plan will pay benefits directly to the providers of your emergency care
providers upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form If you are required to pay for the services submit itemized bills and your receipts to the Plan along
with an explanation of the services and the identification information from your ID card Payment
will be sent to you or the provider if you did not pay the bill unless the claim is denied If it is
denied you will receive notice of the decision including the reasons for the denial and the
provisions of the contract on which denial was based If you disagree with the Plan's decision you
may request reconsideration in accordance with the disputed claims procedure described on page 8
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Mental Conditions Substance Abuse Benefits
Mental conditions To the extent shown below the Plan provides the following services necessary for the diagnosis
What is covered 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 a 10 copay for each covered visit all charges thereafter Outpatient visit
maximums do not apply to members receiving treatment for the following diagnoses
schizophrenia schizo affective disorder bipolar affective disorder major depressive disorder
specific obsessive compulsive disorder or panic disorder
Up to 12 visits per incident for bereavement counseling when arranged by a primary care doctor
and provided by a Plan provider You pay 10 per visit
Inpatient care Up to 45 full days or 90 partial days of hospitalization each calendar year A partial day is defined
as continuous treatment for at least 3 hours but not to exceed 12 hours in any 24 hour period you
pay nothing for the first 45 days or 90 partial days all charges thereafter Inpatient day
limitations do not apply to members receiving treatment for the following diagnoses
schizophrenia schizo affective disorder bipolar affective disorder major depressive disorder
specific obsessive compulsive disorder or panic disorder
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 when not medically necessary to determine the appropriate
treatment of a short term psychiatric condition
Educational and neurodevelopmental testing
Substance abuse 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
What is covered Members are eligible for two complete rehabilitation treatment programs per lifetime A complete treatment program includes a maximum of 30 hours of outpatient and 30 days of residential
inpatient rehabilitative care Once the first rehabilitation treatment program has begun the entire
program must be completed within 12 months Unused portions of the first rehabilitation treatment
program may not be carried over beyond 12 months after the start of the program There is no time
limit for completing the second rehabilitation treatment program You pay nothing
What is not covered Treatment that is not authorized by a Plan doctor
Prescription Drug Benefits
What is covered Prescription drugs listed on the Plan's Formulary and certain medical supplies prescribed by a Plan doctor or referral doctor will be dispensed for up to a 30 day supply or 100 doses whichever is
greater You pay a 10 copay for generic drugs 15 copay for preferred brand name drugs and 25
for non preferred drugs A dose is defined as a single pill regardless of the number of pills to be
taken at a single time For inhalers and medicines available in patch formulation the maximum
quantity dispensed shall be a 30 day supply You may check with your doctor or call Member
Services to determine which drugs or medicines are listed on the formulary
Drugs are reviewed by the Plan for quality therapeutic value and cost effectiveness Based on
these factors drugs are classified and placed on the Plan's formulary
When generic substitution is permissible i e a generic is available and the prescribing doctor
does not require the use of either a preferred name brand or non preferred name drug but you
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Rocky Mountain HMO 2000
request either a preferred name brand or non preferred name brand drug you pay the price
difference between the generic and brand name drug as well as the applicable copay Drugs and
supplies must be obtained by a Plan pharmacy except for medical emergencies The member will
not be required to pay more than the allowed charge for any drug dispensed by a participating
pharmacy If the allowed charge for a drug is less than the co payment amount the member will be
responsible to pay the allowed charge
Covered medications Drugs for which a prescription is required by law
include Oral contraceptives Insulin
Disposable needles and syringes needed for injecting covered prescribed medication
including insulin
Intravenous fluids and medication for home use implantable drugs such as Norplant
some injectable drugs diaphragms IUDs and disposable supplies such as diabetic
supplies are covered under Medical and Surgical Benefits at 100
Fertility drugs with prior authorization
What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available
Vitamins and nutritional substances that can be purchased without a prescription
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Other Benefits
Dental Care The Plan provides preventive dental services to children under age 12 This benefit is limited to two visits per child per calendar year You pay a 10 copay per visit The following dental services
What is covered are covered
Oral exams
Prophylaxis cleaning
Topical application of fluoride if drinking water is not fluoridated
Sealants
Accidental injury benefit Restorative services and supplies necessary to promptly repair or replace sound natural teeth are covered A tooth is not considered sound and natural if it has more than one surface restoration a
crown or root canal and or the tooth is a partial a denture or implant The need for these services
must result from an accidental injury not from biting or chewing Treatment must be completed
within a 24 month period from the date of injury You pay a 10 copay per visit
What is not covered Other dental services not shown as covered
Vision Care
What is Covered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye annual eye refractions to provide a written lens prescription may be obtained from any
licensed optometrist or ophthalmologist within the Plan's service area No referral is required You
pay a 10 copay per visit
What is not covered Eye exercises
Corrective lenses or frames
Vision therapy
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Rocky Mountain HMO 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 who are 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 out of pocket maximum
copay charges etc These benefits are not subject to the FEHB disputed claims procedure
Expanded Dental Benefits
First Year Second Year Third Year
Diagnostic Preventive 80 100 100
Basic Services 50 65 80
Major Services 25 40 50
Annual Program Maximum 1,000.00 1,000.00 1,000.00
Deductible 50 150 50 150 50 150
Deductible does not apply to Diagnostic and Preventive services
No Claim Forms with Participating Providers
Over 50,000 Participating Providers Nationally
With Concordia Select Benefits gradually increase over a three year period
The percentages shown are the percent of the maximum allowance amount for covered service's
For more information call customer service at 1 800 332 0366
Benefits on this page are not part of the FEHB contract
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Rocky Mountain HMO 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
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest
Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan
Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On
occasion you may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain
enrolled with us
If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a
Medicare Choice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a Medicare Choice plan contact your retirement office If you
later want to re enroll in the FEHB Program generally you may do so only at the next Open
Season
If you involuntarily lose coverage or move out of the Medicare Choice service area you may reenroll
in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and
your benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration
SSA office or request it from SSA at 1 800 638 6833 For information on the Medicare Choice
plan offered by this Plan call us at 1 800 453 2981
Other group insurance When anyone has coverage with us and with another group health plan it is called double
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
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Rocky Mountain HMO 2000
Circumstances beyond Under certain extraordinary circumstances we may have to delay your services or be unable to
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 injuries another person caused you must reimburse us for whatever services we paid for We will cover the cost of treatment that exceeds the amount you received in the settlement If you do not seek
damages you must agree to let us try This is called subrogation If you need more information
contact us for our subrogation procedures
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you we are
the primary payer See your TRICARE Health Benefits Advisor if you have questions about
TRICARE coverage
Workers compensation We do not cover services that
You need because of a workplace related disease or injury that the Office of Workers Compensation Programs OWCP or a similar Federal or State agency determine they
must provide
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment we will
provide your benefits
Medicaid We pay first if both Medicaid and this Plan cover you
Other Government We do not cover services and supplies that a local State or Federal Government agency directly or
Agencies indirectly pays for
Section 8 FEHB FACTS
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the
information about your right to information about your health plan its networks providers and facilities You can also find
HMO out about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's website
www opm gov lists the specific types of information that we must make available to you
If you want specific information about us call 800 346 4643 or write to address You may also
contact us by fax at 970 244 7880 attention Member Services
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 FEHB an informed decision about
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
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Rocky Mountain HMO 2000
When your enrollment ends and
The next Open Season for enrollment
We don't determine who is eligible for coverage and in most cases cannot change your enrollment
status without information from your employing or retirement office
When are my benefits and The benefits in this brochure are effective on January 1 If you are new to this plan your coverage
premiums effective and premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants premiums begin January 1
What happens when I When you retire you can usually stay in the FEHB Program Generally you must have been
retire enrolled in the FEHB Program for the last five years of your Federal service If you do not meet this requirement you may be eligible for other forms of coverage such as Temporary Continuation
of Coverage which is described later in this section
What types of coverage Self Only coverage is for you alone Self and Family coverage is for you your spouse and your
are available for my unmarried dependent children under age 22 including any foster or step children your employing
family and me or retirement office authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years of age or older who is incapable of self support
If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry
give birth or add a child to your family You may change your enrollment 31 days before to 60 days
after you give birth or add the child to your family The benefits and premiums for your Self and
Family enrollment begin on the first day of the pay period in which the child is born or becomes an
eligible family member
Your employing or retirement office will not notify you when a family member is no longer eligible
to receive health benefits nor will we Please tell us immediately when you add or remove family
members from your coverage for any reason including divorce
If you or one of your family members is enrolled in one FEHB plan that person may not be
enrolled in another FEHB plan
Are my medical and We will keep your medical and claims information confidential Only the following will have
claims records access to it
confidential OPM this Plan and subcontractors when they administer this contract
This plan and appropriate third parties such as other insurance plans and the Office of Workers Compensation Programs OWCP when coordinating benefit payments and
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
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Rocky Mountain HMO 2000
What if I paid a Your old plan's deductible continues until our coverage begins
deductible under my old
plan
Pre existing conditions We will not refuse to cover the treatment of a condition that you or a family member had before
you enrolled in this Plan solely because you had the condition before you enrolled
When you lose benefits
What happens if my You will receive an additional 31 days of coverage for no additional premium when
enrollment in this Plan Your enrollment ends unless you cancel your enrollment or
ends You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former spouse If you are divorced from a Federal employee or annuitant you may not continue to get benefits
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 32 nd day after your regular coverage ends even if several months have
passed
You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll in TCC If you leave Federal service your employing office will notify you of your right to enroll under TCC You must enroll within 60 days of leaving or receiving this notice whichever is later
Children You must notify your employing or retirement office within 60 days after your child is no
longer an eligible family member That office will send you information about enrolling in TCC
You must enroll your child within 60 days after they become eligible for TCC or receive this
notice whichever is later
Former spouses You or your former spouse must notify your employing or retirement office within
60 days of one of these qualifying events
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Rocky Mountain HMO 2000
Divorce
Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about enrolling
in TCC Your former spouse must enroll within 60 days after the event which qualifies them for
coverage or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify
your employing or retirement office within the 60 day deadline
How can I convert to You may convert to an individual policy if
individual coverage Your coverage under TCC or the spouse equity law ends If you canceled your coverage
or did not pay your premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law
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
Certificate of Group indicates how long you have been enrolled with us You can use this certificate when getting health
Health Plan Coverage insurance or other health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or
exclusions for health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in other
FEHB plans you may request a certificate from them as well
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Rocky Mountain HMO 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 970 243 7050 and explain the situation
If we do not resolve the issue call or write
THE HEALTH CARE FRAUD HOTLINE
202 418 3300
U S Office of Personnel Management
Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400
Washington D C 20415
Penalties for Fraud
Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud Also the Inspector General may
investigate anyone who uses an ID card if they
Try to obtain services for a person who is not an eligible family member or
Are no longer enrolled in the Plan and try to obtain benefits
Your agency may also take administrative action against you
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Rocky Mountain HMO 2000
Summary of Benefits for Rocky Mountain HMO 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions
set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or
change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the
cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY CARE
ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS
Benefits Plan pays provides Page
Inpatient Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes inhospital care doctor care room and board general nursing care private room and private nursing
care if medically necessary diagnostic tests drugs and medical supplies use of operating
room intensive care and complete maternity care You pay nothing 12
Extended All necessary services up to 100 days per member per year You pay nothing 12 care
Mental Diagnosis and treatment of acute psychiatric conditions for up to 45 full days or 90 partial conditions
days of inpatient care per year Treatment for certain diagnoses are not subject to the day
limitation You pay nothing 14
Substance A lifetime maximum of two 30 day rehabilitation treatment programs You pay nothing 14 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 a 10
office visit copy copays are waived for preventive and obstetric care nothing for house calls
by a doctor 12
Home health All necessary visits by nurses and health aides You pay nothing 11 care
Mental Up to 20 outpatient visits per year You pay a 10 copay per visit The treatment of certain conditions diagnoses are not subject to the visit limitation up to 12 visits per incident for bereavement
counseling You pay a 10 copay per visit 14
Substance Up to 30 outpatient visits as part of a rehabilitation treatment program lifetime maximum of abuse
two programs You pay nothing 14
Emergency care Actual charges for services and supplies required because of medical emergency You pay a 50 copay to the hospital for each emergency room visit and any charges for services that are
not covered by this Plan 12
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy 10 Copayment for Generic Drugs 15 Co Payment for Preferred Brand Drugs and 25 Copayment for NonPreferred
Brand Drugs 14
Dental care Accidental injury benefit you pay a 10 copay per visit Preventive dental care for children under 12 you pay a 10 copay per visit 15
Vision care One refraction annually You pay a 10 copay per visit 15
Out of pocket Copayments are required for a few basic benefits however after your out of pocket expenses maximum reach a maximum of 750 per Self Only or 1,500 per Self and Family enrollment per
calendar year covered benefits will be provided at 100 This copay maximum does not
include the costs of prescription drugs or prosthetic devices 6
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Rocky Mountain HMO 2000
Authorized for Distribution by the
United States Office of
Personnel Management
2000 Rate Information for
Rocky Mountain HMO 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 Y our Gov't Y our USPS Y our USPS Y our
Enrollment Code Share Share Share Share Share Share Share Share
Most of Colorado
Self Only 881 4 76.01 9 25.3 0 164.6 5 54.9 0 89.9 5 11.4 0 89.9 11.4
Self and Family 87 82 7 175.9 7 61.0 2 381.2 4 132.3 0 207.7 2 29.3 2 201.0 36.0
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