see
Enrollment in this Plan is limited see page 4 for requirements
Enrollment code 171 Self Only
172 Self and Family
This Plan has commendable accreditation
from the NCQA See the 2000 Guide
for more information on NCQA
Visit the OPM website at http www opm gov insure and
our web site at http www rushpru com
Authorized for distribution by the
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Rush Prudential HMO 2000
Table of Contents
Page Introduction 1
Plain language 1
How to use this brochure 2
Section 1 Health Maintenance Organizations 3
Section 2 How we change for 2000 3
Section 3 How to get benefits 4 6
Section 4 What to do if we deny your claim or request for service 6 8
Section 5 Benefits 8 16
Section 6 General exclusions Things we don't cover 18
Section 7 Limitations Rules that affect your benefits 19 20
Section 8 FEHB FACTS 20 23
Inspector General Advisory Stop Healthcare Fraud 24
Summary of benefits 25
Premiums 26
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Rush Prudential HMO 2000
Introduction
Rush Prudential HMO Inc d b a Rush Prudential HMO Sears Tower 233 S Wacker Dr 39th Flr Chicago IL 60606 6309
This brochure describes the benefits you can receive from Rush Prudential HMO under its contract CS1656 with the Office of
Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law This brochure is the official
statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this brochure If you
are enrolled for Self and Family coverage each eligible family member is also entitled to these benefits
OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on
page 3 Premiums are listed at the end of this brochure
Plain Language
The President and Vice President are making the 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 Rush Prudential 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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Rush Prudential 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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Rush Prudential 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 care
changes office visits
This year you have a right to more information about this Plan care management its 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 Rush Prudential HMO non postal premium will increase by 3.6 for Self Only or
Plan 11.8 for Self and Family
Office visits with Plan primary care doctors and specialists will be subject to a 10 copay per visit See
page 8
Short term rehabilitative therapy will be provided on an inpatient or outpatient basis for up to two
consecutive months per condition only Outpatient therapy will not be extended up to an additional 60
consecutive days per condition Inpatient rehabilitation will continue to be based on medical necessity
See page 10
We will no longer cover ostomy supplies including bags adhesives and skin protectants See page 11
We will no longer cover smoking cessation drugs and medications including but not limited to nicotine
patches and sprays See page 16
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Rush Prudential HMO 2000
Section 3 How to get benefits
What is this To enroll with us you must live or work in our service area Our service area is the Chicago
Plan's service Metropolitan area and includes the Illinois counties of Cook DuPage Kane Kankakee Kendall Lake
area McHenry and Will and the Indiana counties of Lake and Porter This is where our providers practice
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 urgent or emergency care benefits We will not pay for any other
health care services
If you or a covered family member move outside of our service area you can enroll in another plan If
your dependents live out of the area for example if your child goes to college in another state you
should consider enrolling in a fee for service plan or an HMO that has agreements with affiliates in
other areas 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
If you need urgent or emergency care when you are away from home you should call Rush Prudential
HMO at 800 782 0180 Service is available 24 hours a day 7 days a week If your unexpected illness
is not an emergency you should call this number before seeking treatment For life threatening medical
emergencies you should seek treatment from the nearest medical facility and inform the hospital or
physician that you are a member of Rush Prudential HMO You should then contact Rush Prudential
HMO at 800 782 0180 within 24 hours after medical care begins
How much do You must share the cost of some services This is called either a copayment a set dollar amount or
I pay for coinsurance a set percentage of charges Please remember you must pay this amount when you
services receive services
After you pay 2,900 in copayments or coinsurance for one family member or 7,000 for two or more
family members you do not have to make any further payments for certain services for the rest of the
year This is called a catastrophic limit However copayments or coinsurance for your prescription
drugs do not count toward these limits and you must continue to make these payments
Be sure to keep accurate records of your copayments and coinsurance since you are responsible for
informing us when you reach the limits
Do I have to You normally won't have to submit claims to us unless you receive emergency services from a provider
submit claims who doesn't contract with us If you file a claim please send us all of the documents for your claim as soon as possible You must submit claims by December 31 of the year after the year you received the
service Either OPM or we can extend this deadline if you show that circumstances beyond your control
prevented you from filing on time
Who provides Rush Prudential HMO is a mixed model HMO Plan with a broad network of physicians who practice at
my health Rush Prudential managed medical offices or in contracted medical groups Federal employees who
care enroll in our Plan can select a doctor from among more than 2,800 primary care physicians associated with more than 90 hospitals throughout the greater Chicago metropolitan area
What do I do if Call us at 312 234 7747 or 888 234 7747 outside of the Ameritech local calling area We will help
my primary you select a new one
care physician
leaves the Plan
What do I do if Talk to your Plan physician If you need to be hospitalized your primary care physician or specialist
I need to go will make the necessary hospital arrangements and supervise your care
into the
hospital
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Section 3 How to get benefits continued
What do I do if First call our customer service department at 312 234 7747 or 888 234 7747 outside of the Ameritech
I'm in the local calling area If you are new to the FEHB Program we will arrange for you to receive care If you
hospital when are currently in the FEHB Program and are switching to us your former plan will pay for the hospital
I join this Plan 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 become a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do I get Your primary care physician will arrange your referral to a specialist You must contact your primary
specialty care care doctor for a referral before seeing any other doctor or getting special services except in a medical emergency or when a primary care doctor has designated another doctor to see patients Your primary
care doctor will refer you to a network specialist at his or her discretion
You cannot self refer to a specialty provider without written authorization from your primary care
doctor except in the following instance Female members may designate an obstetrician gynecologist
OB GYN also known as a woman's principal health care provider who is in the Plan's network
and see this provider without a written referral Although a woman may directly see her woman's
principal health care provider a referral arrangement must exist between that provider and her PCP so
her care can be coordinated This will eliminate any potential billing issues She must call the Plan's
Member Services Department at 312 234 7747 or 888 234 7747 outside of the Ameritech local calling
area for assistance in designating a provider where the referral arrangement exists
If you need to see a specialist frequently because of a chronic complex or serious medical condition
your primary care physician will develop a treatment plan that allows you to see your specialist for a
certain number of visits without additional referrals Your primary care physician will use our criteria
when creating your treatment plan
What do I do if I Your primary care physician will decide what treatment you need If he she decides to refer you to a
am seeing a specialist specialist ask if you can see your current specialist If your current specialist does not participate with
when I enroll us you must receive treatment from a specialist who does Generally we will not pay for you to see a specialist who does not participate with our Plan
What do I do if my Call your primary care physician who will arrange for you to see another specialist You may be able
specialist leaves to receive services from your current specialist until we can make arrangements for you to see someone
the Plan 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 seeing your provider for up to 90 days after we notify you that we are terminating our contract with the
my provider leaves provider unless the termination is for cause If you are in the second or third trimester of pregnancy
the Plan or this Plan you may continue to see your OB GYN until the end of your postpartum care
leaves the Program You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and
you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic
condition or are in your second or third trimester of pregnancy 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 of pregnancy your new plan will pay for the OB GYN care
you receive from your current provider until the end of your postpartum care
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Section 3 How to get benefits continued
How do you Your physician must get our approval before sending you to a hospital referring you to a specialist or
authorize medical recommending follow up care Before giving approval we consider if the service is medically
services necessary and if it follows generally accepted medical practice
How do you decide We do not cover procedures services or supplies that are experimental or investigational In order to
if a service is determine whether or not a procedure service or supply is experimental or investigational we gather
experimental or appropriate information for a decision that will be made by medical professionals The information we
investigational collect may include medical records current reviews of medical literature and scientific evidence results of current studies or clinical trials research protocols reports or opinions of authoritative
medical bodies opinions of independent outside experts and approvals granted by regulatory bodies
Your provider may sometimes ask that you sign a form acknowledging that the procedure service or
supply is experimental or investigational This form and any related protocol may also be part of the
information we consider After reviewing all pertinent information we make our determination and
notify you of our decision If you would like any additional information you may call us at 312 234
7747 or 888 234 7747 outside of the Ameritech local calling area
Section 4 What to do if we deny your claim or request for service
If we deny services or 1 Be in writing
won't pay your claim
you may ask us to 2 Refer to specific brochure wording explaining why you believe our decision is wrong and
reconsider our 3 Be made within six months from the date of our initial denial or refusal We may extend this time
decision Your limit if you show that you were unable to make a timely request due to reasons beyond your
request must control
We have 30 days 1 Maintain our denial in writing
from the date we
receive your 2 Pay the claim
reconsideration 3 Arrange for a health care provider to give you the service or
request to
4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must
make a decision within 30 days after we receive the additional information If we do not receive the
requested information within 60 days we will make our decision based on the information we already
have
When may I ask You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal OPM
OPM to review will determine if we correctly applied the terms of our contract when we denied your claim or request
a denial for service
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Section 4 What to do if we deny your claim or request for service continued
What if I have a Call us at 312 234 7747 or 888 234 7747 outside of the Ameritech local calling area and we will
serious or expedite our review
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 lifethreatening
condition is serious conditions are ones that may cause permanent loss of bodily functions or death if they are
or life threatening 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 initial
time limits denial or refusal of service You may also ask OPM to review your claim if
1 We did 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 do 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 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
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Section 4 What to do if we deny your claim or request for service continued
Where should I mail Send your request for OPM review to Office of Personnel Management Office of Insurance Programs
my disputed claim Contract Division 3 P O Box 436 Washington D C 20044
What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our decision
upholds the Plan's your only recourse is to sue
denial If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third
year after the year in which you received the disputed services or supplies
What laws apply if Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its
I file a lawsuit review on the record that was before OPM when OPM made its decision on your claim You may recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment
services supplies or drugs covered by us until you have completed the OPM review procedure
described above
Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and us
the Privacy Act to determine if our denial of your claim is correct The information OPM collects during the review process becomes a permanent part of your disputed claims file and is subject to the provisions of the
Freedom of Information Act and the Privacy Act OPM may disclose this information to support the
disputed claim decision If you file a lawsuit this information will become part of the court record
Section 5 Medical and Surgical Benefits
What is covered Plan doctors and other Plan providers supply a comprehensive range of preventive diagnostic and treatment services This includes all necessary office visits laboratory tests and X rays you pay a 10
copay for each office visit but no additional copays for authorized laboratory tests and x rays Within
the service area house calls will be provided if in the judgment of the Plan doctor such care is
necessary and appropriate you pay a 10 copay for a doctor's house call but no copay 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 and over one mammogram every year 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
8 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Section 5 Medical and Surgical Benefits continued
What is covered Complete obstetrical maternity care for all covered females including prenatal delivery and continued postnatal care by a Plan doctor You pay a 10 copay for the initial maternity visit and nothing for
subsequent maternity office visits 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 you terminate enrollment in the plan 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 FDA approved implantable and injectable
contraceptives
Diagnosis and treatment of infertility including artificial insemination in vitro fertilization uterine
embryo lavage embryo transfer gamete intrafallopian tube transfer zygote intrafallopian tube
transfer and low tubal ovum transfer Coverage for in vitro fertilization shall be available only if
the covered individual has been unable to attain or sustain a successful pregnancy through
reasonable less costly medically appropriate infertility treatments for which coverage is available
Additionally the covered individual has not undergone four completed oocyte retrievals per
lifetime except that if a live birth follows a complete oocyte retrieval then two more completed
oocyte retrievals shall be covered Artificial insemination is limited to intrauterine insemination
IUI and intracervical insemination ICI The cost of donor sperm is not covered Fertility drugs
that are administered in the doctor's office not self injected are covered subject to the 10 office
visit copay Self injectable fertility drugs are covered under Prescription Drug 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 artificial joints breast prostheses
and surgical bras The cost of the device is covered
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
Home health services of nurses and health aides including intravenous fluids and medications
when prescribed by your Plan doctor who will periodically review the program for continuing
appropriateness and need
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and
other Plan providers
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 9
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Section 5 Medical and Surgical Benefits continued
What is covered Oxygen and rental of equipment for use of oxygen continued
Administration of blood or blood plasma
Diabetic supplies and glucometers for diabetes treatment
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 Extraction of completely 100 bony impacted teeth is covered All
other procedures involving the teeth or intra oral areas surrounding the teeth are not covered including
any dental care involved in the treatment of temporomandibular joint TMJ pain dysfunction syndrome
unless there is acute trauma or system wide disease and there is objective radiological evidence of joint
disease You pay 50 of charges for approved treatment of TMJ pain dysfunction syndrome
Reconstructive surgery will be provided to correct a condition resulting from a functional defect or
from an injury or surgery that has produced a major effect on the member's appearance and if the
condition can reasonably be expected to be corrected by such surgery A patient and her attending
physician may decide whether to have breast reconstruction surgery following a mastectomy and
whether surgery on the other breast is needed to produce a symmetrical appearance
Short term rehabilitative therapy physical speech and occupational therapy is provided on an
inpatient or outpatient basis for up to two consecutive months per condition you pay a 10 copay per
outpatient visit 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 Rehabilitation is based on medical necessity
Durable medical equipment and prosthetic devices Benefits are provided for the purchase or rental
up to the purchase price of medically necessary equipment including hospital beds wheelchairs
artificial limbs eyes and lenses following cataract removal You pay 20 of the charges for equipment
and devices after you have satisfied a calendar year deductible of 100 per Self Only enrollment and
300 per Self and Family enrollment
Cardiac rehabilitation program following a heart transplant bypass surgery or a myocardial
infarction is provided as determined to be medically necessary you pay a 10 copay per office visit
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 and the cost of cochlear implant devices
Homemaker services
Biofeedback
Long term rehabilitative therapy
Chiropractic services
10 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Section 5 Medical and Surgical Benefits continued
What is not Orthopedic devices such as braces foot orthotics orthopedic shoes unless permanently attached to
covered an approved device continued
Any eye surgery solely for the purpose of correcting refractive defects of the eye such as
nearsightedness myopia farsightedness hyperopia and astigmatism
All ostomy supplies including bags adhesives and skin protectants
Section 5 Hospital Extended Care Benefits
What is covered
Hospital care We cover 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
Administration of blood and blood plasma
Extended care We cover a comprehensive range of benefits for up to 120 days of care 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 We cover supportive and palliative care for a terminally ill member in the home or hospice facility Coverage is provided up to a maximum benefit of 10,000 per period of care Services include
inpatient and outpatient care and family counseling Covered hospice 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
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis
detoxification treatment of medical conditions and medical management of withdrawal symptoms acute detoxification if the Plan doctor determines that outpatient management is not medically appropriate
See page 14 for non medical substance abuse benefits
What is not Personal comfort items such as telephone and television
covered Custodial care rest cures domiciliary or convalescent care
Hospitalization for dental procedures
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11
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Section 5 Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe
emergency endangers your life or could result in serious injury or disability and requires immediate medical or surgical care Some problems are emergencies because if not treated promptly they might become
more serious examples include deep cuts and broken bones Others are emergencies because they are
potentially life threatening such as heart attacks strokes poisonings gunshot wounds or sudden
inability to breathe There are many other acute conditions that we 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 your primary care doctor In extreme emergencies if
within the 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
service area that you are a Plan member so they can notify the Plan You or a family member must notify us within 48 hours unless it was not reasonably possible to do so It is your responsibility to ensure that we have
been timely notified
If you need to be hospitalized in a non Plan facility we must be notified within 48 hours or on the first
working day following your admission unless it was not reasonably possible to notify us within that
time If you are hospitalized in a non Plan facility 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
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
We pay 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 for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital we waive the emergency care copay
Emergencies Benefits are available for any medically necessary health service that is immediately required because
outside the of injury or unforeseen illness
service area If you need urgent or emergency medical care when you're away from home you should call the Rush Prudential HMO at 800 782 0180 Service is available 24 hours a day 7 days a week If your
unexpected illness is not an emergency you must call this number before seeking treatment For lifethreatening
medical emergencies you should seek treatment from the nearest medical facility and
inform the hospital or physician that you are a member of Rush Prudential HMO You should then
contact Rush Prudential HMO at 800 782 0180 within 24 hours after medical care begins
If you need to be hospitalized we must be notified within 48 hours or on the first working day
following your admission unless it was not reasonably possible to notify us 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
We pay Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
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Section 5 Emergency Benefits continued
You pay 25 per hospital emergency room or urgent care center visit for emergency services that are covered benefits of the Plan If the emergency results in admission to a hospital we waive the emergency care
copay
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 we will pay benefits directly to the providers of your emergency care upon
for non Plan 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 us along with an explanation
providers of the services and the identification information from your ID card
We will send payment to you or the provider if you did not pay the bill unless we deny benefits for
the claim If we deny benefits we will send you a written notice of our decision including the reasons
for the denial and the provisions of the contract on which we based our decision If you disagree with
us you may ask us to reconsider our decision in accordance with the disputed claims procedure
described on pages 6 and 7
Section 5 Mental Conditions Substance Abuse Benefits
Mental Conditions
What is covered To the extent shown below we provide 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 for medical diagnostic services
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Outpatient care We cover up to 20 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year You pay a 25 copay for each covered visit and all charges thereafter Group outpatient
visits may be substituted on a 2 to 1 basis for individual mental health care visits as deemed appropriate
by the Rush Prudential HMO primary care doctor
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 13
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Section 5 Mental Conditions Substance Abuse Benefits continued
Inpatient care We cover up to 30 days of hospitalization each calendar year You pay nothing for the first 30 days and all charges thereafter Care in a day hospital may be substituted on a 2 to 1 basis for inpatient hospital
services as deemed appropriate by the Rush Prudential HMO primary care doctor
What is not Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to covered significant improvement through relatively short term treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless
determined by a Plan doctor to be necessary and appropriate
Psychological testing that is not medically necessary to determine the appropriate treatment of a
short term psychiatric condition
Marriage and lifestyle counseling
Substance Abuse
What is covered We provide medical and hospital services such as acute detoxification services for the medical nonpsychiatric aspects of substance abuse including alcoholism and drug addiction the same as for any
other illness or condition Services for the psychiatric aspects are provided in conjunction with the
mental conditions benefit Outpatient visits to Plan mental health providers for follow up care and
counseling are covered as well as inpatient services necessary for diagnosis and treatment The mental
conditions benefit visit day limitations and copays apply
In addition to the psychiatric treatment covered under the mental conditions benefit we provide the
following non psychiatric treatment
Outpatient care Up to 20 outpatient visits for the non psychiatric treatment of substance abuse per calendar year you pay nothing The sessions may be either individual or group therapy as determined by the Plan
Inpatient care Up to 10 days of inpatient non psychiatric hospitalization per calendar year for treatment of substance abuse you pay nothing Alcohol and substance abuse care in a day hospital residential non hospital or
intensive outpatient treatment mode may be substituted on a 2 to1 basis for inpatient hospital services as
deemed appropriate by the Rush Prudential HMO primary care doctor
What is not Treatment that is not authorized by a Plan doctor covered
14 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Section 5 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 8oz
60 grams of ointment creams or topical preparation or one commercially prepared unit i e one
inhaler You pay a 5 copay per prescription unit or refill for generic drugs or for name brand drugs
when generic substitution is not permissible When generic substitution is permissible i e a generic
drug is available and the prescribing doctor does not require the use of a name brand drug but you
request the name brand drug you pay the 5 copay plus the difference between the cost of the generic
drug and the cost of the name brand drug
Mail Order Members may obtain up to a 90 day supply of certain maintenance medications through Rush
Pharmacy Prudential's mail order pharmacy program A Plan doctor must prescribe all covered medication You pay a 5 copay per 30 day supply prescription unit or refill for generic drugs or for name brand drugs
when generic substitution is not permissible less a 10 discount You subtract the discount from the
90 day supply copay you send to our mail order pharmacy along with the appropriate paperwork
Maintenance medications are drugs used on a continual basis for treatment of chronic health conditions
such as high blood pressure ulcers or diabetes and that are packaged and intended for selfadministration
by the patient Additionally insulin and select oral contraceptives may be obtained
through the pharmacy mail order program The mail order pharmacy program does not cover all
prescribed medications We do not classify antibiotics cough syrup drugs that do not require a
prescription and self injected drugs except insulin as maintenance medications These drugs are not
available through the mail order pharmacy program
To order maintenance medications by mail
Call Rush Prudential's Member Services Department at 312 234 7747 or 888 234 7747 outside of
the Ameritech local calling area to obtain the necessary forms
Complete or have your Plan doctor complete the prescription order form Mail the Plan doctor's
written prescription for up to a 90 day supply of the maintenance drug along with the completed
prescription order form and the appropriate copay amount to the mail order vendor Additional
refills may be obtained the same way provided the strength and dosage of the medication remain
the same
Prescription Drug A committee of primary care physicians and medical directors developed our drug formulary
Formulary Committee members review newly FDA approved products and select products that offer clear clinical
Development benefits Products that are judged to provide additional clinical efficiency compared with current formulary agents are added to the formulary and those agents that are judged to not provide a clinical
advantage over current formulary agents are not added to the formulary or are removed from the list
The list of formulary drugs is subject to change periodically
Drugs are dispensed in accordance with the Plan's drug formulary Pre authorization may be required
for certain drugs Non formulary drugs will be covered when prescribed by a Plan doctor
Covered medications and accessories include
Drugs for which a prescription is required by Federal law
Insulin a copy charge applies to a one month supply
Self injectable drugs you pay 50 of the cost of the drug up to an out of pocket maximum of
2,500 per calendar year After you have paid 2,500 during the calendar year we will cover selfinjectable
drugs at 100 for the rest of that year
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 15
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Oral contraceptives up to a six month supply You pay a 5 copay per one month's supply
Disposable needles and syringes needed to inject covered prescribed medication
Self injectable fertility drugs you pay 50 of the charges for self injectable fertility drugs up to an
out of pocket maximum of 2,500 per calendar year After you have paid 2,500 during the
calendar year we cover self injectable fertility drugs at 100 for the rest of that year
Fertility drugs administered in the doctor's office not self injected intravenous fluids and medication
for home use implantable drugs contraceptive devices and injectable drugs that can only be
administered by a physician are covered under Medical and Surgical Benefits
Limited benefits Drugs prescribed for sexual dysfunction have dispensing limitations For complete details please call the Rush Prudential customer service phone number shown on your ID card
What is not Drugs available without a prescription over the counter covered
Drugs for which there is a non prescription equivalent
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 but not limited to nicotine patches and sprays
Smoking cessation classes
Drugs used for the purpose of weight loss or weight gain
Section 5 Other Benefits
Dental care
Accidental injury Restorative services and supplies necessary to promptly repair but not replace sound natural teeth you benefit pay nothing The need for these services must result from an accidental injury Restorative services
must be initiated within 60 days of the reported injury unless the member's medical condition is such
that a delay in initiating treatment is required The injury must be reported to the Plan as soon as
reasonably possible after the accident
What is not Other dental services not shown as covered covered
Vision care
What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye all medically necessary eye refractions to provide a written lens prescription for eyeglasses for
members under the age of 18 one refraction every 24 months for enrollees age 18 and older may be
obtained from Plan providers You pay 10
What is not Corrective lenses or frames or the fitting of contact lenses covered
Eye exercises
16 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Rush Prudential 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 any charges for these services do not count toward any FEHB deductibles or out of pocket maximum
These benefits are not subject to the FEHB disputed claims procedures
Dental Benefits
As a Rush Prudential HMO member you and your family are automatically eligible for DNoA Select a dental network offered by the
Dental Network of America DNoA By taking advantage of this non FEHB benefit you and your family will be able to choose a
dental provider from an extensive network of participating credentialed dental providers in the Chicagoland area And you will be able
to receive a 10 to 40 discount on a wide range of preventive and specialty care services from participating dental providers
including orthodontists After you enroll in Rush Prudential HMO we will send you a DNoA identification card You must call DNoA
at 800 367 1203 to select a convenient dental office near you If you have questions you may also contact Rush Prudential HMO
Member Services at 312 234 7747 or 888 234 7747 outside of the Ameritech local calling area
Vision Care
As a Rush Prudential HMO member you and your family are entitled to discounts off the retail price on eye wear from more than 50
Cole Vision Centers in the Chicagoland area These discounts are in addition to your covered eye refractions explained on the previous
page Cole Vision Centers are conveniently located in most Sears Montgomery Ward JC Penney and Carson Pirie Scott stores Call
the Cole Vision Customer Service Center at 1 800 334 7591 to find a convenient location near you Then just present your Rush
Prudential HMO ID card at a Cole Vision Center to receive your discount If you have questions you may also contact Rush Prudential
HMO Member Services at 312 234 7747 or 888 234 7747 outside of the Ameritech local calling area
BENEFITS ON THIS PAGE ARE NOT PART OF THE FEHB CONTRACT 17
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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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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 coverage
insurance 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 provide
beyond our control them In that case we will make all reasonable efforts to provide you with necessary care
When others are When you receive money to compensate you for medical or hospital care for injuries or illness that
responsible for another person caused you must reimburse us for whatever services we paid for We will cover the cost
injuries 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
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Section 7 Limitations Rules that affect your benefits continued
Workers We do not cover services that
compensation You need because of a workplace related disease or injury that the Office of Workers
Compensation Programs OWCP or a similar Federal or State agency determine they must
provide
OWCP or a similar agency pays for through a third party injury settlement or other similar
proceeding that is based on a claim you filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment we will provide
your benefits
Medicaid We pay first if both Medicaid and this Plan cover you
Other Government We do not cover services and supplies that a local State or Federal Government agency directly or
Agencies indirectly pays for
Section 8 FEHB FACTS
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right to
information about information about your health plan its networks providers and facilities You can also find out about
your HMO care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's website www opm gov lists
the specific types of information that we must make available to you
If you want specific information about us call 312 234 7747 or 888 234 7747 outside of the
Ameritech local calling area or write to the plan at Rush Prudential HMO Inc Sears Tower 233 S
Wacker Dr 39th Flr Chicago IL 60606 6309 You may also contact us by fax at 312 234 7001
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal
information about Employees Health Benefits Plans brochures for other plans and other materials you need to make an
enrolling in the informed decision about
FEHB Program When you may change your enrollment
How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter military
service or retire
When your enrollment ends and
The next Open Season for enrollment
We don't determine who is eligible for coverage and in most cases cannot change your enrollment
status without information from your employing or retirement office
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Section 8 FEHB FACTS continued
When are my The benefits in this brochure are effective on January 1 If you are new to this plan your coverage and
benefits and premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants
premiums effective premiums begin January 1
What happens When you retire you can usually stay in the FEHB Program Generally you must have been enrolled
when I retire 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 or
available for retirement office authorizes coverage for Under certain circumstances you may also get coverage for a
my family and me 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 access to
claims records 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 SF2809 or the OPM annuitant confirmation letter until you receive your ID card You can also use an
Employee Express confirmation letter
What if I paid a Your old plan's deductible continues until our coverage begins
deductible under
my old plan
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Section 8 FEHB FACTS continued
Pre existing We will not refuse to cover the treatment of a condition that you or a family member had before you
conditions enrolled in this Plan solely because you had the condition before you enrolled
When you lose benefits
What happens You will receive an additional 31 days of coverage for no additional premium when
if my enrollment
in this Plan ends Your enrollment ends unless you cancel your enrollment or You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits under
spouse coverage your former spouse's enrollment But you may be eligible for your own FEHB coverage under the spouse equity law If you are recently divorced or are anticipating a divorce contact your ex spouse's
employing or retirement office to get more information about your coverage choices
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For example you can
receive TCC if you are not able to continue your FEHB enrollment after you retire You may not elect
TCC if you are fired from your Federal job due to gross misconduct Get the RI 79 27 which describes
TCC and the RI 70 5 the Guide to Federal Employees Health Benefits Plans for Temporary
Continuation of Coverage and Former Spouse Enrollees from your employing or retirement office
Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from
the 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
How do I enroll If you leave Federal service your employing office will notify you of your right to enroll under TCC
in 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
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Section 8 FEHB FACTS continued
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 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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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 312 234 7747 or 888 234 7747 outside of the Ameritech local calling area
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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Rush Prudential HMO 2000
Summary of Benefits for Rush Prudential 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 Care Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes in hospital doctor care room and board general nursing care
private room and private nursing care if medically necessary diagnostic tests drugs and medical supplies use of operating room intensive care and complete
maternity care You pay nothing 11
Extended care All necessary services up to 120 days per year You pay nothing 11
Mental conditions Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per year You pay nothing 13
Substance abuse Covered under Mental conditions In addition up to 10 days of non psychiatric hospitalization for substance abuse treatment per calendar year
You pay nothing 14
Outpatient care Comprehensive range of services such as diagnosis and treatment of illness or injury including specialist's care preventive care including well baby care
periodic check ups and routine immunizations laboratory tests and X rays complete maternity care You pay a 10 copay for an office visit or a house
call by a doctor 8
Home health care All necessary visits by nurses and health aides You pay nothing 9
Mental conditions Up to 20 outpatient visits per year You pay a 25 copay per visit 13
Substance abuse Covered under Mental conditions In addition up to 20 outpatient visits for non psychiatric substance abuse treatment per calendar year
You pay nothing 14
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 25 copay to the hospital for each emergency room
visit and any charges for services that are not covered benefits of this Plan 12
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5 copay per prescription unit or refill for a generic drug and the
difference in cost between a generic and a name brand drug if you request a name brand A 90 day supply of maintenance medications can be mailed
for a copayment of 13.50 This reflects an additional 10 off the member's normal copayment of 5 per 30 day supply 15
Dental care Accidental injury benefit you pay nothing Preventive dental care no current benefit 16
Vision care Eye refractions You pay a 10 copay 16
Out of pocket Copayments are required for a few benefits however after your out of pocket maximum expenses reach a maximum of 2,900 per Self Only or 7,000 per Self and
Family enrollment per calendar year covered benefits will be provided at 100 This copay does not include charges for prescription drugs 4
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2000 Rate Information for Rush Prudential 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
Biweekley Monthly Biweekly Biweekly
Type of Enrollment Code Gov't Your Gov't Your USPS Your USPS Your Share Share Share Share Share Share Share Share
Self Only 171 66.68 22.22 144.47 48.15 78.90 10.00 78.90 10.00
Self and Family 172 173.04 57.68 374.92 124.97 204.76 25.96 201.02 29.70
26 28