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Health Maintenance Plan 2000 A Health Maintenance Organization
For changes
Serving Most of Ohio in benefits see page 5

Enrollment in this Plan is limited See page 6 for requirements
Enrollment code R51 Self Only
R52 Self and Family

This Plan has full accreditation From the NCQA See the 2000 guide
For more information on NCQA

Visit the OPM websete at http www opm gov insure and
Our website at http www anthem inc com

Authorized for distribution by the
UNITED STATES OFFICE OF PERSONNEL MANAGEMENT
RETIREMENT AND INSURANCE SERVICE
RI 73 031 1
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Table of Contents
Introduction 1
Plain language 1
How to use this brochure 1
Section 1 Health Maintenance Organizations 2
Section 2 How we change for 2000 3
Section 3 How to get benefits 4
Section 4 What to do if we deny your claim or request for service 7
Section 5 Benefits 9
Section 6 General exclusions Things we don't cover 18
Section 7 Limitations Rules that affect your benefits 19
Section 8 FEHB facts 21
Inspector General Advisory Stop Healthcare Fraud 24
Summary of benefits Inside Back Cover

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Introduction Introduction
Health Maintenance Plan HMP 1351 William Howard Taft Road Cincinnati OH 45206 1775
This brochure describes the benefits you can receive from Community Insurance Company dba Anthem Blue Cross and Blue Shield under its contract CS1659 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 An independent licensee of the Blue Cross and Blue Shield Association Anthem Blue Cross and Blue Shield is the trade name of Community Insurance Company Registered marks Blue Cross and Blue Shield Association

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 Health Maintenance Plan as HMP or 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

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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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

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Section 2 How We Change For 2000
Program wide changes 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 increase by 5 for Self Only or 3.5 for Self and Family
The office visit copay increases from 5 to 10
The Prescription Drug benefit has changed to include a Formulary Drug program See page 14 for details

The days supply for the Prescription Drug mail order program has been increased from a 60 day to a 90 day supply See page 14 for details
Diabetic supplies including insulin syringes needles glucose test tablets and test tape Benedict's solution or equivalent glucose monitors and acetone test tablets are now covered under the
Prescription Drug benefits These items may now be purchased through any Community Rx National Network pharmacy or through the prescription drug mail order program The copayment
for these services will be reduced from a 50 copayment with a maximum benefit of 1,500 per member per calendar year to a 12 copayment per prescription unit for a 30 day supply at the
retail pharmacy or a 24 copayment for a 90 day supply through the prescription drug mail order program with no calendar year maximum

Disposable needles and syringes needed to inject covered prescribed medications are now covered under the prescription drug benefit

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Section 3 How To Get Benefits
What is this Plan's To enroll with us you must live or work in our service area This is where our providers practice service area Our service area is

Cincinnati Area In Ohio Brown Butler Clermont Clinton Hamilton and Warren counties and ZIP codes 45110 and 45142 in Highland County
Cleveland Area In Ohio Cuyahoga Geauga Lake Lorain Medina and Summit counties and ZIP codes 44032 44033 44066 44076 44084 44085 44093 and 44099 in Ashtabula County
Dayton Area In Ohio Butler Champaign Clark Clinton Greene Miami Montgomery Preble Shelby and Warren counties ZIP codes 45304 45313 45328 45329 45331 45332
45336 45352 45358 and 45380 in Darke County 43128 and 43142 in Fayette County and 43310 43311 43318 43319 43324 43331 43333 43343 and 43357 in Logan County

Akron Canton Area In Ohio Ashland Carroll Harrison Holmes Medina Portage Stark Summit Tuscarawas and Wayne counties
Warren Youngstown Area In Ohio Columbiana Jefferson Mahoning and Trumbull counties
Columbus Area In Ohio Coshocton Delaware Fairfield Franklin Licking Pickaway and Union counties and ZIP codes 43029 43064 43140 43143 43151 43153 and 43162 in Madison

County
Toledo Defiance Area In Ohio Allen Defiance Erie Fulton Hancock Henry Huron Lucas Ottawa Paulding Putnam Seneca Williams and Wood counties ZIP codes 43407 43410

43420 43431 43435 43442 43448 43469 and 44841 in Sandusky County and 45832 45863 45886 and 45891 in Van Wert County

Ordinarily you must get your care from providers who contract with us If you receive care outside our service area we will pay only for emergency care or urgent 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 HMP offers guest memberships at affiliated HMO plans through HMO
Blue USA Whenever you or a family member are away from the HMP service area for more than 90 days you may become a guest member at an affiliated HMO near your out of area location
Refer to the non FEHB benefits page 17 for details If you or a family member move you do not have to wait until Open Season to change plans Contact your employing or retirement office

How much do I pay You must share the cost of some services This is called either a copayment a set dollar amount for services or coinsurance a set percentage of allowable charges Please remember you must pay this
amount when you receive services
After you pay 1,500 in copayments or coinsurance for one family member or 3,000 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 or 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 submit You normally won't have to submit claims to us unless you receive emergency services from a 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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Who provides my As a plan member you will receive care from one of Health Maintenance Plan's participating health care primary care doctors These doctors are under contract to HMP to provide care to HMP members
Primary care doctors practicing within a Plan Medical Center as well as those doctors with medical offices in the surrounding communities are part of the Plan medical team The Plan refers

to this combination of group and private practice doctors as a mixed model prepayment plan The Plan has designated certain hospitals for organ transplants to be performed These hospitals have
been selected for their experience in performing transplants In some instance the designated hospital may not be located in the Plan's service area and you will be responsible for your travel
expenses to that facility Contact the Plan for a list of designated organ transplant facilities

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

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

What do I do if I'm First call our customer service department at 1 800 228 4375 If you are new to the FEHB in the hospital when Program we will arrange for you to receive care If you are currently in the FEHB Program and
I join this Plan 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 Except in a medical emergency or when a primary care doctor has designated another doctor to see specialty care patients when he or she is unavailable you must contact your primary care doctor for a referral
before seeing any other doctor or obtain special services Referral to a participating specialist is given at the primary care doctor's discretion if specialists or consultants are required beyond
those participating in the Plan the primary care doctor will make arrangements for appropriate referrals

Do not go to the specialist unless a referral has been placed in your files with your primary care doctor and the Plan All follow up care must be provided or authorized by the primary care doctor
On referrals the primary care doctor will give specific instructions to the consultant as to what services are authorized If additional services or visits are suggested by the consultant you must
first check with your primary care doctor If you are receiving services from a doctor who leaves the Plan the Plan will pay for covered services until the Plan can arrange with you for you to be
seen by another participating doctor
If you have a chronic complex or serious medical condition that causes you to see a Plan specialist frequently your primary care doctor will develop a treatment plan with you and your

health plan that allows an adequate number of direct access visits with that specialist The treatment plan will permit you to visit your specialist with the need to obtain further referrals
Contact your primary care doctor for authorization
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 specialist ask if you can see your current specialist If your current specialist does not participate

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

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But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to serious illness and my continue seeing your provider for up to 90 days after we notify you that we are terminating our
provider leaves the contract with the provider unless the termination is for cause If you are in the second or third Plan or this Plan trimester of pregnancy you may continue to see your OB GYN until the end of your postpartum
leaves the Program care You may also be able to continue seeing your provider if your plan drops out of the FEHB
Program and you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic condition or are in your second or third trimester Your new plan will pay for
or provide your care for up to 90 days after you receive notice that your prior plan is leaving the FEHB Program If you are in your second or third trimester your new plan will pay for the
OB GYN care you receive from your current provider until the end of your postpartum care
How do you Your physician must get our approval before sending you to a hospital referring you to a authorize medical specialist or recommending follow up care Before giving approval we consider if the service is

services medically necessary and if it follows generally accepted medical practice
How do you decide if a A drug device or biological product is experimental or investigational if the drug device or service is experimental biological product cannot be lawfully marketed without approval of the U S Food and Drug

or investigational Administration FDA and approval for marketing has not been given at the time it is furnished Approval means all forms of acceptance by the FDA

A medical treatment or procedure or a drug device or biological product is experimental or investigational if 1 reliable evidence shows that it is the subject of ongoing phase I II or III
clinical trials or under study to determine its maximum tolerated dose its toxicity its safety its efficacy or its efficacy as compared with the standard means of treatment or diagnosis or 2
reliable evidence shows that the consensus of opinion among experts regarding the drug device or biological product or medical treatment or procedure is that further studies or clinical trials are
necessary to determine its maximum tolerated dose its toxicity its safety its efficacy or its efficacy as compared with the standard means of treatment or diagnosis

Reliable evidence shall mean only published reports and articles in the authoritative medical and scientific literature the written protocol or protocols used by the treating facility or the protocol s
of another facility studying substantially the same drug device or medical treatment or procedure or the written informed consent used by the treating facility or by another facility studying
substantially the same drug device or medical treatment or procedure If you desire additional information concerning the experimental investigational determination process please contact the
Plan

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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 You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal to 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 Call us at 1 800 228 4375 and we will expedite our review serious or life
threatening condition and you haven't
responded to my request for service

What if you have If we expedite your review due to a serious medical condition and deny your claim we will inform denied my request OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's
for care and my health benefits Contract Division II at 202 606 3818 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
or life threatening are not treated as soon as possible

Are there other time You must write to OPM and ask them to review our decision within 90 days after we uphold our limits
initial denial or refusal of service You may also ask OPM to review your claim if

1 We do not answer your request within 30 days In this case OPM must receive your request within 120 days of the date you asked us to reconsider your claim

2 You provided us with additional information we asked for and we did not answer within 30 days In this case OPM must receive your request within 120 days of the date we asked you
for additional information
What do I send to Your request must be complete or OPM will return it to you You must send the following OPM information

1 A statement about why you believe our decision is wrong based on specific benefit provisions in this brochure

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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

What if OPM upholds OPM's decision is final There are no other administrative appeals If OPM agrees with our the 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 Federal law governs your lawsuit benefits and payment of benefits The Federal court will base file a lawsuit its review on the record that was before OPM when OPM made its decision on your claim You
may recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment services supplies or drugs covered by us until you have completed the OPM review procedure

described above
Your records and the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you Privacy Act and us to determine if our denial of your claim is correct The information OPM collects during

the review process becomes a permanent part of your disputed claims file and is subject to the provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this
information to support the disputed claim decision If you file a lawsuit this information will become part of the court record

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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 but

no additional costs for 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
nothing for a doctor's house call or home visits by nurses and health aides
The following services are included
Preventive care including well baby care and periodic check ups
Mammograms are covered as follows for women age 35 through age 39 one mammogram during these five years for women age 40 through 49 one mammogram every one or two years for

women age 50 through 64 one mammogram every year and for women age 65 and above one mammogram every two years In addition to routine screening mammograms are covered when
prescribed by the doctor as medically necessary to diagnose or treat your illness
Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor The mother at her option may remain in the hospital up to 48 hours

after a regular delivery and 96 hours after a caesarean delivery Inpatient stays will be extended if medically necessary If enrollment in the Plan is terminated during pregnancy benefits will not be
provided after coverage under the Plan has ended Ordinary nursery care of the newborn child during the covered portion of the mother's hospital confinement for maternity will be covered under
either a Self Only or Self and Family enrollment other care of an infant who requires definitive treatment will be covered only if the infant is covered under a Self and Family enrollment

Voluntary sterilization and family planning services you pay 20 of allowable charges
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing and treatment materials such as allergy serum You pay 20 of allowable charges

The insertion of internal prosthetic devices such as pacemakers and artificial joints The cost of the devices is covered except for penile or cochlear implants
Cornea heart heart lung single and double lung pancreas kidney and liver transplants Allogeneic donor bone marrow transplants autologous bone marrow transplants autologous stem cell and
peripheral stem cell support for 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 and breast cancer multiple myeloma and epithelial ovarian cancer Related medical and hospital expenses of the donor are covered when the
recipient is covered by this Plan You pay nothing when the transplant is performed in a Plandesignated organ transplant facility or when a member requires a particular transplant and the Plan
does not have a reasonably located Plan designated organ transplant facility available You pay 20 of the allowable charges when the transplant or follow up care for transplant is provided in a
participating nondesignated organ transplant facility Contact the Plan for further information on designated organ transplant facilities

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

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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 at no additional cost to you except as noted above

Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or surgical procedures occurring
within or adjacent to the oral cavity or sinuses including but not limited to treatment of fractures and excision of tumors and cysts All other procedures involving the teeth or intra oral areas surrounding
the teeth are not covered including any dental care involved in the treatment of temporomandibular joint TMJ pain dysfunction or syndrome Medical treatment related to temporomandibular joint
disease is covered in full up to 200 Appliances are subject to durable medical equipment copay
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 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
Benefits will be provided for breast reconstruction surgery following a mastectomy including surgery to produce a symmetrical appearance on the other breast Benefits will be provided for all stages of

breast reconstruction following a mastectomy including treatment of any physical complications including lymphedemas and for breast prostheses including surgical bras and replacements

Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis for up to two consecutive months per condition if significant improvement can be
expected within two months you pay nothing per outpatient session Speech therapy is limited to treatment of certain speech impairments of organic origin Occupational therapy is limited to services
that assist the member to achieve and maintain self care and improved functioning in other activities of daily living Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial
infarction is provided
Diagnosis and treatment of infertility is covered you pay 20 of allowable charges The following types of artificial insemination are covered intravaginal insemination IVI intracervical insemination

ICI and intrauterine insemination IUI you pay 20 of allowable charges cost of donor sperm is not covered Fertility drugs are covered Refer to Prescription Drug Benefits on pages 14 15 for
benefit limitations that apply to infertility drugs Other assisted reproductive technology ART procedures such as in vitro fertilization and embryo transfer are not covered

Durable medical equipment such as wheelchairs and hospital beds orthopedic devices such as braces prosthetic devices such as artificial limbs and first pair of lenses following cataract removal
and medical supplies such as oxygen surgical dressings and colostomy bags are covered up to a maximum Plan benefit of 1,500 per member per calendar year you pay 50 of allowable charges
all charges thereafter

What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance attending school or camp or travel

Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic purposes
Other transplants not specified as covered
Travel expenses related to transplant benefits
Hearing aids
Routine podiatric services
Chiropractic services
Homemaker services
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Sleep disorders except when preauthorized by the Plan
Foot orthotics and special foot shoes
Long term rehabilitative therapy

Hospital Extended Care Benefits
What is covered
Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan doctor You pay nothing except you pay 20 of allowable

charges for organ transplants in participating non designated organ transplant facilities Contact the Plan for a list of designated organ transplant facilities where transplants are covered in full 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 up to 180 days per calendar year when full time skilled nursing care is necessary and confinement in a skilled nursing facility is medically necessary as
determined by a Plan doctor and approved by the Plan You pay nothing for the first 30 days a 50 copay per day for days 31 180 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

Ambulance Service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor You pay 20 of allowable charges
Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need procedures for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the

hospitalization but not the cost of the professional dental services Conditions for which hospitalization would be covered include hemophilia and heart disease the need for anesthesia by
itself is not such a condition
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis detoxification treatment of medical conditions and medical management of withdrawal symptoms acute
detoxification if the Plan doctor determines that outpatient management is not medically appropriate See page 13 for nonmedical substance abuse benefits

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

Emergency Benefits

What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe emergency endangers your life or could result in serious injury or disability and requires immediate medical or
surgical care Some problems are emergencies because if not treated promptly they might become more serious examples include deep cuts and broken bones Others are emergencies because they are
potentially life threatening such as heart attacks strokes poisonings gunshot wounds or sudden inability to breathe There are many other acute conditions that the Plan may determine are medical
emergencies what they all have in common is the need for quick action
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Emergencies within If you are in an emergency situation you must contact your primary care doctor In extreme the service area emergencies if you are unable to contact your doctor contact the local emergency system e g the
911 telephone system or go to the nearest hospital emergency room Be sure to tell the emergency room personnel that you are a Plan member so you may notify the Plan You or a family member must

notify your primary care doctor within 24 hours unless it was not reasonably possible to do so It is your responsibility to ensure that your primary care doctor has been timely notified

If you need to be hospitalized the Plan must be notified within 24 hours or on the first working day following your admission unless it was not reasonably possible to notify the Plan within that time If
you are hospitalized in non Plan facilities and Plan doctors believe care can be better provided in a Plan hospital you will be transferred when medically feasible with any ambulance charges covered in
full
Benefits are available for care from non Plan providers in a medical emergency only if you believe 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 25 per hospital emergency room visit or 5 per urgent care center visit for urgent care services that are covered benefits of this Plan If the emergency results in admission to a hospital the emergency
copay is waived

Emergencies outside Benefits are available for any medically necessary health service that is immediately required because the service area 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 services to the extent the services would have been covered if received from Plan providers

You pay 25 per hospital emergency room visit or 5 per urgent care center visit for urgent care services that are covered benefits of this Plan If the emergency results in admission to a hospital the emergency
copay is waived
What is covered Urgent 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 if approved by the Plan subject to copay see page 11

What is not covered Elective care or nonemergency care
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area

Medical and hospital costs resulting from a normal full term delivery of a baby outside the service area

Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency care non Plan 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

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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 pages 7 8

Mental Conditions Substance Abuse Benefits
Mental conditions
What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions including the treatment of mental illness or disorders

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

Outpatient care Up to 20 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year you pay nothing for visits 1 10 50 of allowable charges for visits 11 20 all charges thereafter

Inpatient care Up to 45 days of hospitalization each calendar year you pay nothing for first 45 days you will be responsible for all charges thereafter
What is not covered Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to significant improvement through relatively short term treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless determined by a Plan doctor to be necessary and appropriate
Psychological testing when not medically necessary to determine the appropriate treatment of a short term psychiatric condition

Substance abuse
What is covered This Plan provides medical and hospital services such as acute detoxification services for the medical non psychiatric aspects of substance abuse including alcoholism and drug addiction the same as for

any other illness or condition and to the extent shown below the services necessary for diagnosis and treatment

Outpatient care Up to 20 outpatient visits to Plan providers for treatment for each calendar year you pay nothing for visits 1 10 a 50 copay for visits 11 20 all charges thereafter These substance abuse benefits may be
combined with the outpatient mental conditions benefit shown above provided such treatment is necessary as a mental health service and is approved by the Plan to permit an additional 20 outpatient
visits per calendar year with the applicable mental conditions copayments

Inpatient care Up to 45 days hospitalization per member per calendar year These days count against those inpatient days available under the mental conditions benefit Lifetime maximum of two 28 day substance abuse
rehabilitation intermediate care programs in an alcohol detoxification or rehabilitation center approved by the Plan you pay nothing

What is not covered Treatment that is not authorized by a Plan doctor

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 13 15
15 Page 16 17
Prescription Drug Benefits Prescription drugs prescribed by a Plan or referral doctor and obtained at a Community Rx National
Network pharmacy will be dispensed for up to a 30 day supply or one commercially prepared unit i e one inhaler one vial opthalmotic medication or insulin Per prescription unit or refill you pay

5 copay for generic drugs
12 copay for formulary name brand drugs and
24 copay for non formulary name brand drugs
Members may also obtain up to a 90 day supply of continuous therapy medications by mail order Per prescription unit or refill you pay

10 copay for generic drugs
24 copay for formulary name brand drugs and
36 copay for non formulary name brand drugs

Formulary Prescription drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's Prescription prescription drug formulary All prescription drugs on the formulary have been approved by the Food

Drugs and Drug Administration FDA The formulary consists of medications that have been rigorously reviewed and selected by a committee of practicing doctors and clinical pharmacists for their safety
quality and effectiveness Coverage will be provided for both formulary and non formulary medications when prescribed by a Plan doctor

To order by mail Send your prescription in the easy order envelope attached to the Anthem Rx program brochure along with a check money order or credit card information to cover the cost of your
copayment With each filled prescription you will receive an easy order envelope When it is time for a refill just mail your request or phone in your refill to 1 800 962 8192 Prescriptions are not
automatically refilled
If you receive a name brand drug whether by mail order or from a Network pharmacy the copayment for the name brand applies regardless of whether

no generic equivalent is available
the prescription order specifies Dispense as Written or
you choose the name brand drug instead of a generic drug
Covered medications and accessories include
Drugs for which a prescription is required by Federal law
FDA approved prescription drugs and devices for birth control
Insulin
Disposable needles and syringes needed to inject covered prescribed medications are covered at the name brand copayment

Immuno Suppressive Agent you pay 50 of allowable charges
Infertility drugs you pay 50 of allowable charges
Human growth hormones you pay 50 of allowable charges

Smoking cessation drugs and medications you pay 50 of allowable charges The drugs and medications are limited to one 12 week treatment per lifetime upon proof of enrollment in a
smoking cessation program
Diabetic supplies including insulin syringes needles glucose test tablets and test tape Benedict's solution or equivalent glucose monitors and acetone test tablets are covered at the name brand

copayment

14 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 16
16 Page 17 18
Drugs for the treatment of impotence such as Viagra HMP requires proof of medical necessity prior to approving benefits Then this Plan will cover a maximum of six tablets per month subject
to the following guidelines The patient
must be a male over age 18
is being treated for erectile dysfunction ED regardless of the cause and
is not on medication containing nitrates
Intravenous fluids and medications for home use implantable drugs and some injectable drugs such as Depo Provera are covered under Medical and Surgical Benefits

What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available
Drugs obtained at a Non network 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
The cost of smoking cessation programs
Drugs for weight loss purposes except when authorized by the Plan doctor for treatment of morbid obesity

Replacement prescriptions such as lost stolen or spilled Other Benefits

Dental care
What is covered The following dental services are covered when provided by participating Plan dentists and indicates
copayments where they apply This benefit description does not list exclusions Contact the Plan for specific exclusions at 1 800 228 4375 or 513 872 8242 in the local dialing area

DIAGNOSTIC You Pay PREVENTIVE You Pay X rays including bite wings and panoramic oral Prophylaxis annual topical application of fluoride
examinationsand treatment plan vitality test and to children age 12 preventive dental instructions NOTHING oral cancer exam NOTHING Space maintainers

RESTORATIVE Fillings for primary teeth 80 of allowable charge Amalgam one surface 80 of allowable charge Stainless steel crown
Amalgam two surfaces 80 of allowable charge for primary teeth 80 of allowable charge Amalgam three surfaces Bridge abutments or pontics 80 of allowable charge
Build up per tooth 80 of allowable charge PERIODONTICS Under local anesthetics Plastic or composite single surface 80 of allowable charge Examination treatment plan 80 of allowable charge
Plastic or composite two surfaces 80 of allowable charge Periodontal root planning and
ORAL SURGERY including preoperative and curettage 80 of allowable charge postoperative treatments under local anesthetics Hemisection 80 of allowable charge

Extraction simple 80 of allowable charge Gingivectomy or gingivoplasty 80 of allowable charge Alveolectomy per quadrant 80 of allowable charge Osseous surgery per quadrant 80 of allowable charge
Impaction soft tissue 80 of allowable charge Equilibration entire mouth 80 of allowable charge Impaction partial bony 80 of allowable charge ENDODONTICS under local anesthetics
Impaction complete bony 80 of allowable charge Pulpotomy including restoration 80 of allowable charge
PROSTHODONTICS Root canal filling one canal 80 of allowable charge Complete upper or lower denture 80 of allowable charge Each additional canal 80 of allowable charge

Cast chrome partial Upper or lower 80 of allowable charge Apicoectomy performed as separate Acrylic partial upper or lower surgical procedure 80 of allowable charge
with clasps 80 of allowable charge ORTHODONTICS braces Repair broken denture 80 of allowable charge Initial Consultation 80 of allowable charge
Denture adjustment 80 of allowable charge Diagnosis and treatment plan 80 of allowable charge Reline upper or lower complete denture Limited to one two year course of phase II treatment per
or partial office 80 of allowable charge eligible child up to age 19 Reline upper or lower complete denture Missed appointments without 24 hours prior notification 10
or partial laboratory 80 of allowable charge

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 15 17
17 Page 18 19
Accidental injury Restorative services and supplies necessary to promptly repair within three days of accident but not benefit replace sound natural teeth are covered The need for these services must result from an accidental
injury You pay nothing
What is not covered Other dental services not shown as covered
Vision care
What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye annual eye refractions which include the written lens prescription may be obtained from Plan

providers You pay a 10 copay per visit

What is not covered Eye exercises vision training
Frames
Eyeglasses or contact lenses
Radial keratotomy

16 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 18
18 Page 19 20
Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made available to all enrollees and family members of this Plan The cost of the benefits described on this page is not introduced in the FEHB premium

any charges for these services do not count toward any FEHB deductibles out of pocket maximum co pay charges etc These benefits are not subject to the FEHB disputed claims procedures

HMO Blue USA
HMP participates in HMO Blue USA the national HMO network sponsored by the Blue Cross and Blue Shield Association It provides for you and your family to receive urgent care at other Blue Cross and Blue Shield HMO Plans while traveling outside the service area of

HMP
You have the option of obtaining care under HMP's out of area guidelines or under HMO Blue USA Simply call 1 800 4 HMO USA You'll be given the location and phone number of the participating HMO covering that location and the name of the away from home

care coordinator who will schedule an appointment for you Your membership with HMP will be verified and you will receive services You will pay nothing at the time you receive services Applicable HMP copayments will be billed by HMP after you return home

HMP offers guest memberships at affiliated HMO plans through HMO Blue USA Whenever you or a family member is away from the HMP service area for more than 90 days you may become a guest member at an affiliated HMO near your destination Reasons to
consider a guest membership include extended out of town business children away at school dependent children in another state or a winter snowbird residency in the South To determine if a guest membership is available at your destination call 1 800 4 HMO USA

Medicare Choice prepaid plan enrollment
This Plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare Choice As indicated on page 19 annuitants and former spouses with FEHB coverage and Medicare Part B may elect to drop their FEHB coverage and enroll in a Medicare Choice

prepaid plan when one is available in their area They may then later reenroll in the FEHB Program Most Federal annuitants have Medicare Part A Those without Medicare Part A may join this Medicare prepaid plan but will probably have to pay for hospital coverage
in addition to the Part B premium Before you join the plan ask whether the plan covers hospital benefits and if so what you will have to pay Contact your retirement system for information on dropping your FEHB enrollment and changing to a Medicare prepaid plan
Contact us at 1 888 641 5220 for information on the Medicare Choice prepaid plan and the cost of that enrollment
Personal Health Advisor
Plan members have access to Personal Health Advisor PHA a health information service 24 hours a day seven days a week All calls are completely confidential Members can

1 Speak with a registered nurse for help with everyday health decisions and for health counseling on chronic conditions
2 Listen to pre recorded health care topics in the AudioHealth Library
3 Locate doctors and hospitals in their area

HMP members can access Personal Health Advisor by calling 1 888 474 2258 or through the internet website www pha online com anthem

Anthem Advantage
Plan members receive negotiated savings on selected health and wellness services and programs simply by being an eligible Anthem Blue Cross and Blue Shield Health Maintenance Plan member Companies participating in the Anthem Advantage program include

Bally Total Fitness special savings on fitness memberships Beltone free hearing exams and discounts on hearing aids
The Lighthouse Catalog preferred pricing on vision enhancement products for people with impaired vision Mature Mart discounts on life enhancing products for mature adults
Priorities discounts on asthma and allergy relief products Revive A Lens mail order contact lens cleaning
Safe Beginnings discounts on child proofing and family safety products Vision One discounts on frames contacts bifocals
Weight Watchers preferred pricing on weight management programs SafeTech a div of Troxel preferred pricing on bicycle and in line skating helmets
YMCA preferred pricing on fitness memberships for the whole family Dayton Cleveland Hamilton Ohio only Quality Books and Audio discounts on health education books and cassettes

Benefits on this page are not part of the FEHB contract 17 19
19 Page 20 21
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

18 20
20 Page 21 22
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 see page 17
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
injuries cost of treatment that exceeds the amount you received in the settlement If you do not seek damages you must agree to let us try This is called subrogation If you need more information contact us for
our subrogation procedures

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

Worker's 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

19 21
21 Page 22 23
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

20 22
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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 information about to information about your health plan its networks providers and facilities You can also find out
your HMO 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 1 800 228 4375 or write to Mail No CC1 014 1351 William Howard Taft Road Cincinnati OH 45206 1775 You may also contact us by fax at

513 872 3929 or visit our website at www anthem inc com
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal information about
Employees Health Benefits Plans brochures for other plans and other materials you need to make an enrolling in the FEHB 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

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 The benefits in this brochure are effective on January 1 If you are new to this plan your coverage and and premiums premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants
effective premiums begin January 1
What happens when When you retire you can usually stay in the FEHB Program Generally you must have been enrolled 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 available unmarried dependent children under age 22 including any foster or step children your employing or
for me and my family 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 access claims records to it
confidential OPM this Plan and subcontractors when they administer this contract
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions
OPM and the General Accounting Office when conducting audits 21 23
23 Page 24 25
Individuals involved in bona fide medical research or education that does not disclose your identity or
OPM when reviewing a disputed claim or defending litigation about a claim
Information for new members
Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You can also use an

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

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

When you lose benefits
What happens if my You will receive an additional 31 days of coverage for no additional premium when enrollment in this
Your enrollment ends unless you cancel your enrollment or Plan ends
You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage

What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits 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 32 nd day after your regular coverage ends even if several months have passed

You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits

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How do I enroll in If you leave Federal service your employing office will notify you of your right to enroll under TCC TCC You must enroll within 60 days of leaving or receiving this notice whichever is later
Children You must notify your employing or retirement office within 60 days after your child is no longer an eligible family member That office will send you information about enrolling in TCC You
must enroll your child within 60 days after they become eligible for TCC or receive this notice whichever is later

Former spouses You or your former spouse must notify your employing or retirement office within 60 days of one of these qualifying events
Divorce
Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about 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 insurance or other health care coverage You must arrange for the other coverage within 63 days of 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

23 25
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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 1 800 848 9276 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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Summary of Benefits for Health Maintenance Plan 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to enroll or change

your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF EMERGENCY CARE
ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS
Benefits Plan 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 except organ
transplants performed in participating non designated organ transplant facilities are subject to different copays 11

Extended care All necessary services up to 180 days per calendar year You pay nothing for first 30 days and a 50 copay per day for days 31 180 11
Mental Diagnosis and treatment of acute psychiatric conditions for up to 45 days of inpatient care conditions per year You pay nothing 13
Substance abuse Subject to mental conditions day limits up to a lifetime maximum of two 28 day substance abuse programs You pay nothing 13

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 10 per office visit nothing per house call by a doctor 9 10

Home health All necessary visits by nurses You pay nothing 9 10 care
Mental Up to 20 outpatient visits per year You pay nothing for visits 1 10 50 of allowable conditions charges for visits 11 20 13
Substance abuse Up to 20 outpatient visits per year You pay nothing for visits 1 10 50 of allowable charges for visits 11 20 13
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 by this Plan If the emergency results in admission to a hospital the

emergency copay is waived 11 12
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Network pharmacy per prescription unit
or refill for up to a 30 day supply you pay a 5 copay for generic drugs a 12 copay for formulary name brand drugs and a 24 copay for non formulary name brand drugs A mail

order drug program is available per prescription unit or refill for up to a 90 day supply you pay a 10 copay for generic drugs a 24 copay for formulary name brand drugs and a 36
copay for non formulary name brand drugs 14 15
Dental care Accidental injury benefit you pay nothing preventive dental care comprehensive range of
restorative orthodontic and other services You pay 80 of allowable charge for most services 15 16

Vision care One refraction annually you pay a 10 copay per visit 16
Out of pocket maximum Copayments are required for a few benefits however after your out of pocket expenses
reach a maximum of 1,500 per Self Only or 3,000 per Self and Family enrollment per calendar year covered benefits will be provided at 100 This copay maximum does not

include prescription drugs or dental services 4

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

applicable Guide to Federal Employees Health Benefits Plans

Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly

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

Most of Ohio
Self Only R51 74.87 24.96 162.23 54.07 88.60 11.23 88.60 11.23
Self and Family R52 169.21 56.40 366.62 122.20 200.23 25.38 200.23 25.38

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