QualMed
Plans for Health Inc 2000
A Health Maintenance Organization For changes
in benefits See page 5
Serving Philadelphia and seven adjacent counties in
Southeastern Pennsylvania and New Jersey
Enrollment in this plan is limited see page 9 for requirements
Enrollment Code 271 Self Only
272 Self and Family
Serving Scranton Wilkes Barre area
Enrollment Code 2K1 Self Only
2K2 Self and Family
Visit the OPM website at http www opm gov insure
or the Plan's website at http www qualmed com
Authorized for distribution by the
United States
Office of
Personnel
Management
QualMed Plans for Health 2000
Table of Contents
Introduction 2
Plain Language 2
How to use this brochure 3
Section 1 Health Maintenance Organizations 4
Section 2 How we change for 2000 5
Section 3 How to get benefits 6
Section 4 What to do if we deny your claim or request for service 8
Section 5 Benefits 10
Section 6 General Exclusions Things we don't cover 19
Section 7 Limitations Rules that affect your benefits 20
Section 8 FEHB facts 22
Inspector General Advisory Stop Healthcare Fraud 26
Summary of Benefits Inside back cover
Premiums Back cover
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QualMed Plans for Health 2000
Introduction
QualMed Plans for Health Inc 11 Penn Center 1835 Market Street 9 TH Floor Philadelphia PA 19103
This brochure describes the benefits you can receive from QualMed Plans for Health under its contract CS1743 with the Office of
Personnel Management OPM as authorized by the Federal Employees Health Benefits FEHB law This brochure is the official
statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this brochure If you
are enrolled for Self and Family coverage each eligible family member is also entitled to these benefits
OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on
page 5 of this brochure 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 person pronouns active voice and short sentences
We refer to QualMed Plans for Health 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 service 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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QualMed Plans for Health 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 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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QualMed Plans for Health 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 coinsurances 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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QualMed Plans for Health 2000
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
changes primary care office visits
This year you have a right to more information about this plan care management our
networks facilities and providers
If you have a chronic or disabling condition and your provider leaves the Plan at our request
you may continue to see your specialist for up to 90 days If your provider leaves the Plan and
you are in the second or third trimester of pregnancy you may be able to continue seeing your
OB GYN until the end of your postpartum care You have similar rights if this Plan leaves the
FEHB program See Section 3 How to get benefits for more informatiom
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 relevant or complete If the physician does not amend
your record you may add a brief statement to the record 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 For Code 27 your share of the premium will increase by 31.0 for Self Only or 28.6 for Self
Plan and Family
For Code 2k your share of the premium will increase by 3.8 for Self Only or 3.8 for Self
and Family
The Plan now covers all diabetes equipment supplies and outpatient self management
training and education
We now provide more outpatient visits for care for serious mental illnesses Inpatient mental
health care can be converted to outpatient care
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QualMed Plans for Health 2000
Section 3 How to Get Benefits
What is this Plan's service To enroll with us you must live or work in our service area This is where our providers
area practice Our service area is The Pennsylvania counties of Bucks Chester Delaware Lackawanna Luzerne Montgomery and Philadelphia and the New Jersey counties of
Camden Burlington and Gloucester
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 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
How much do I pay for You must share the cost of some services This is called either a copyament a set dollar
services amount or coinsurance a set percentage of charges Please remember you must pay this amount when you receive services
Your out of pocket expenses for benefits covered under this Plan are limited to the stated
copayments which are required for a few benefits
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 claims You normally won't have to submit claims to us unless you receive emergency services from a provider who doesn't contract with us If you file a claim please send us all of the documents
for your claim as soon as possible You must submit claims by December 31 of the year after
the year you received the service Either OPM or we can extend this deadline if you show that
circumstances beyond your control prevented you from filing on time
Who provides my health QualMed Plans for Health arranges for the provision of services through contracted doctors
care nurse practitioners physician assistants and other skilled medical personnel at participating medical centers or offices Your medical records will be maintained at the Plan medical office
of your choice and your primary health care will be provided by appointment at that office
Except for emergencies all care must be provided by or arranged for you through the primary
care physician that you choose
What do I do if my primary Call our customer service department at 1 800 736 2096 We will help you select a new one
care physician leaves the
plan
What do I do if I need to go Talk to your Plan physician If you need to be hospitalized your primary care physician or
into the hospital specialist will make the necessary hospital arrangements and supervise your care
What do I do if I'm in the First call our customer service department at 1 800 736 2096 If you are new to the FEHB
hospital when I join this Program we will arrange for you to receive care If you are currently in the FEHB Program
Plan and are switching to us your former plan will pay for the hospital stay until
You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or
The 92 nd day after you became a member of the Plan whichever happens first
These provisions only apply to the person who is hospitalized
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QualMed Plans for Health 2000
Section 3 How to Get Benefits cont
How do I get specialty care Your primary care physician will arrange your referral to a specialist A woman may see her plan gynecologist for her exams without a referral
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 am seeing a Your primary care physician will decide what treatment you need If they decide to refer you
specialist when I enroll to a specialist ask if you can see your current specialist If your current specialist does not participate 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 specialist Call your primary care physician who will arrange for you to see another specialist You may
leaves the Plan receive services from you current specialist until we can make arrangements for you to see someone else
But what if I have a serious Please contact us if you believe your condition is chronic or disabling You may be able to
illness and my provider continue seeing your provider for up to 90 days after we notify you that we are terminating our
leaves the Plan or this Plan contract with the provider unless the termination is for cause If you are in the second or
leaves the Program third trimester of pregnancy you may continue to see your OB GYN until the end of your postpartum 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 authorize Your physician must get our approval before sending you to a hospital referring you to a
medical services specialist or recommending follow up care Before giving approval we consider if the service is medically necessary and if it follows generally accepted medical practice
How do you decide if a The following describes this Plan's criteria for determining when a medical treatment or
service is experimental or procedure or a drug device or biological product is experimental or investigational
investigational As determined by the PLAN a drug device medical treatment or procedure is experimental or
investigational i if the drug or device cannot be lawfully marketed without the approval of
the U S Food and Drug Administration and approval for marketing has not been given at the
time the drug or device is furnished or ii if the drug device medical treatment or procedure
or the patient informed consent document utilized with the drug device treatment or
procedure was reviewed and approved by the treating facility's Institutional Review Board or
other body serving a similar function or if federal law requires such review and approval or
iii if Reliable Evidence shows that the drug device medical treatment or procedure is the
subject of on going phase I and phase II clinical trials is the research experimental study or
investigational arm of on going phase III clinical trials or is otherwise under study to
determine its maximum tolerated dose its toxicity its safety its efficacy or its efficacy
compared with a standard means of treatment or diagnosis or iv if Reliable Evidence shows
that the prevailing opinion among experts regarding the drug device 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 a standard
means of treatment or diagnosis As used here Reliable Evidence shall mean only as
determined by the PLAN 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 medical treatment
or procedure or the written informed consent used by the treating facility or by another
facility studying substantially the same drug device medical treatment or procedure
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QualMed Plans for Health 2000
Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that
you were unable to make a timely request due to reasons beyond your control
We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30
days after we receive the additional information If we do not receive the requested information within 60 days we will make our
decision based on the information we already have
When may I ask OPM to You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal
review a denial OPM will determine if we correctly applied the terms of our contract when we denied your claim or request for service
What if I have a serious or Call us 1 800 507 3337 and we will expedite our review
life threatening condition
and you haven't responded
to my request for service
What if you have denied my If we expedite your review due to a serious medical condition and deny your claim we will
request for care and my inform OPM so that they can give your claim expedited treatment too Alternatively you can
condition is serious or life call OPM's health benefits Division IV at 202 606 0737 between 8 a m and 5 p m Serious or
threatening life threatening conditions are ones that may cause permanent loss of bodily functions or death if they are not treated as soon as possible
Are there other time limits You must write to OPM and ask them to review our decision within 90 days after we uphold our initial denial or refusal of service You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your request
within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30
days In this case OPM must receive your request within 120 days of the date we asked you
for additional information
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Section 4 What to do if we deny your claim or request for service cont
What do I send to OPM Your request must be complete or OPM will return it to you You must send the following information
1 A statement about why you believe our decision is wrong based on specific benefit
provisions in this brochure
2 Copies of documents that support your claim such as physicians letters operative reports
bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to
which claim
Who can make the request Those who have a legal right to file a disputed claim with OPM are
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 address should I send Send your request for review to Office of Personnel Management Office of Insurance
my disputed claim to Programs Contract Division IV P O Box 436 Washington D C 20044
What if OPM upholds the OPM's decision is final There are no other administrative appeals If OPM agrees with our
Plan's denial decision your only recourse is to sue
If you decide to sue you must file the suit against OPM in Federal court by December 31 of the
third year after the year in which you received the disputed services or supplies
What laws apply if I file a Federal law governs your lawsuit benefits and payment of benefits The Federal court will base
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 you 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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QualMed Plans for Health 2000
Section 5 Benefits
Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits
You pay A 10 office visit copay but no additional copay for laboratory tests and X rays Within the service area house calls will be provided if in the judgement of the Plan doctor such care is
necessary and appropriate
You pay You pay nothing for a house call by a doctor and nothing for home visits by nurses and health
aides Plan doctors also provide all necessary medical or surgical care in a hospital or extended
care facility at no additional cost to you
The following services are included and are subject to the office visit unless otherwise stated
Preventive care including well baby care and periodic check ups Routine immunizations and boosters except for travel and conditions of employment
Consultations by specialists Complete obstetrical maternity care for all covered females including prenatal delivery
and postnatal care by a Plan doctor or nurse midwife If enrollment in the Plan is terminated
during pregnancy benefits will not be provided after coverage under the Plan has ended
Voluntary sterilization you pay a 100 copayment for sterilization and family planning services
Diagnosis and treatment of diseases of the eye Allergy testing and treatment including test and treatment materials such as allergy serum
The following services are included and are not subject to the office visit
Diagnostic procedures such as laboratory tests and X rays 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
Surgical treatment of morbid obesity The insertion of internal prosthetic devices such as pacemakers and artificial joints
including the cost of the device implantable drugs Dental implants are not covered
Breast prothesis and surgical bras Norplant and Depo Provera
Cornea heart kidney kidney pancreas and liver transplants allogenic donor bone marrow transplants autologous bone marrow transplants as medically indicated
Transplants are covered when approved by the Plan Medical Director Related medical and
hospital expenses of the donor are covered when the recipient is covered by the Plan
Dialysis Chemotherapy and radiation therapy and inhalation therapy
Home health services of nurses and home health aides including intravenous fluids and medications when in lieu of hospitalization and 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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN CONTRACTED DOCTORS
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QualMed Plans for Health 2000
Medical and Surgical Benefits cont
Limited benefits Oral and maxillofacial surgery is provided for non dental 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 except the
extraction of bony impacted wisdom teeth involving the teeth or areas surrounding the teeth are
not covered Procedures for cosmetic purposes including shortening of the mandible or
maxillae correction of malocclusion and any dental care involved in treatment of temporomandibular
joint TMJ pain dysfunction syndrome are not covered
Reconstructive surgery will be provided to correct a condition resulting from a functional defect
or from an injury or surgery that has produced a major effect on the member's appearance and if
the condition can reasonably be expected to be corrected by such surgery A patient and her
attending physician may decide whether to have breast reconstruction surgery following a
mastectomy and whether surgery on the other breast is needed to produce a symmetrical
appearance
Short term rehabilitative therapy physical speech and occupational is provided on an inpatient
or outpatient basis for up to two months per condition if significant improvement can be
expected within two months you pay nothing Inpatient services require prior authorization
Speech therapy is limited to treatment of certain speech impairments of organic origin but not
developmental in nature 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
Diagnosis and treatment of infertility is covered you pay nothing for the initial evaluation and
50 of professional and facility costs as contracted by the Plan after the initial evaluation
Artificial insemination is covered you pay 50 of the cost limited to six cycles Cost of donor
sperm is not covered Fertility drugs are not covered Other assisted reproductive technology
ART procedures such as in vitro fertilization and embryo transfer are not covered
For external prosthetic devices such as artificial limbs you pay a 100 deductible per calendar
year
Durable medical equipment you pay a 100 deductible per calendar year subject to 25,000
lifetime maximum
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
Orthopedic devices such as permanent braces and foot orthotics except to correct for missing portions
Reversal of voluntary surgically induced sterility Plastic surgery primarily for cosmetic purposes
Hearing aids Chiropractic services
Homemaker services Long term rehabilitative therapy
Organ transplants not specified as covered Cardiac rehabilitation
Corrective eyeglasses frames and contact lenses including the fitting of contact lenses except as necessary for the first pair of corrective lenses following cataract surgery
Blood and blood derivatives not replaced by the member 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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN CONTRACTED DOCTORS
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QualMed Plans for Health 2000
Hospital Extended Care Benefits
What is covered
Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan doctor You pay nothing All necessary services are
covered including
Semiprivate room accommodations when the Plan determines it is medically necessary the doctor may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units
Extended care The Plan provides a comprehensive range of benefits for up to 120 days per calendar year when full time skilled nursing care is necessary and confinement in a skilled nursing facility is
medically appropriate as determined by the Plan You pay nothing All necessary services are
covered including
Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled
nursing facility when prescribed by a Plan doctor
Hospice Care Supportive and palliative care for a terminally ill member is covered in the home or hospice facility Services include inpatient and outpatient care and family counseling these services are
provided under the direction of a Plan doctor who certifies that the patient is in terminal stages
of illness with a life expectancy of approximately six months or less
Ambulance service Benefits are provided for medically necessary ambulance transportation ordered or authorized by a Plan doctor
Limited Benefits
Inpatient Dental Hospitalization for certain dental procedures is covered when the Plan determines there is need
Procedures for hospitalization for reasons totally unrelated to the dental procedure in order to safequard the medical condition of the patient The Plan will cover the hospitalization but not the cost of the
professional services from doctors dentists or other medical professionals nor any hospital
charges such as anesthesia directly related to dental care 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
Detoxification diagnosis 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 15 for non medical substance abuse benefits
What is not covered Personal comfort items such as telephone and television Custodial care rest cures domiciliary or convalescent care
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN CONTRACTED DOCTORS
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QualMed Plans for Health 2000
Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of a condition or an injury that you
emergency believe endangers your life or could result in a 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
Emergencies within the If you are in a non threatening emergency situation please call your primary care doctor In
service area life threatening emergencies if you are unable to contact your doctor contact the local emergency system e g the 911 telephone system or go to the nearest hospital emergency
room Be sure to tell the emergency room personnel that you are a Plan member so they can
notify the Plan You or a Family member should notify the Plan within 48 hours It is your
responsibility to ensure that the plan has been timely notified
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 you are hospitalized in non Plan facilities and Plan doctors believe care can be
better provided in a Plan hospital you may be transferred when medically stable with any
ambulance charges covered in full
Benefits are available for care from non Plan providers in a medical emergency only if delay in
reaching a Plan provider would result in death disability or significant jeopardy to your
condition To be covered by this Plan any follow up care recommended by non Plan providers
must be approved by the Plan or provided by Plan providers
Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 25 per hospital emergency room visit or urgent care center visit for emergency services which are covered benefits of this Plan If the emergency results in admission to hospital the
emergency care copay is waived
Emergencies outside the Benefits are available for any medically necessary health service that is immediately required
service area because of injury or unforeseen illness
If you need to be hospitalized the Plan must be notified within 48 hours or on the first working
day following your admission unless it was not reasonably possible to notify the Plan within
that time If a Plan doctor believes care can be better provided in a Plan hospital you will be
transferred when medically feasible with any ambulance charges covered in full To be covered
by this Plan any follow up care recommended by non Plan providers must be approved by the
Plan or provided by Plan providers
Plan pays Reasonable charges for emergency care services to the extent the services would have been covered if received from Plan providers
You pay 25 per hospital emergency room visit or per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital the
emergency care copay is waived
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN CONTRACTED DOCTORS
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Emergency Benefits cont
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 determined by the Plan to be medically necessary
What is not covered Elective care or non emergency care Emergency care provided outside the service area if the need for care could have been
foreseen before leaving the service area
Medical and hospital costs resulting from a normal full term delivery of a baby outside the service area Travel restrictions apply after 36 weeks of gestation
Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency
non Plan providers care upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form If you are required to pay for the services submit itemized bills and your receipts to
the Plan along with an explanation of the services and the identification information from your
ID card
Payment will be sent to you or the provider if you did not pay the bill unless the claim is
denied If it is denied you will receive notice of the decision including the reasons for the
denial and the provisions of the contract on which denial was based If you disagree with the
Plan's decision you may request reconsideration in accordance with the disputed claims
procedure described on page 19
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QualMed Plans for Health 2000
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 or other psychiatric personnel each calendar year you pay nothing for the first 6 visits per year 10 copayment per visit for visits 7 15 a 25
copayment per visit for visits 16 20 you pay all charges thereafter Serious Mental Illness is
covered for an additional 40 outpatient mental health service visits per months per benefit year
you pay a 25 copayment per visit Serious mental illness means any of the following mental
ilnesses as defined by the American Psychiatric Association in the most recent edition of the
diagnostic and statical manual schizophrenia bipolar disorder obsessive compulsive disorder
major depressive disorder panic disorder anorexia nervosa schizo affective disorder and
delusional disorder
Inpatient care Up to 30 days of hospitalization each calendar year you pay nothing for the first 30 days you pay all charges thereafter Inpatient days can be converted to outpatient care on a one for two
basis
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 except for initial testing to formulate a diagnosis Neuropsychological testing except prior to epilepsy surgery
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 or equivalent partial visits per member per year to a licensed treatment
facility that is a participating provider The Plan at its discretion may exchange 30 outpatient
visits on a two for one basis for up to 15 additional non hospital residential days The services
are limited to a lifetime maximum of 120 full outpatient visits or an equivalent number of
partial visits You pay nothing for the covered visits
Inpatient care Up to 30 days per member per year for residential substance abuse treatment services in a
licensed treatment facility that is a participating provider You pay nothing for the first 30 days
each calendar year you pay all charges thereafter The benefit the Plan provides is also subject
to a lifetime maximum of 90 days you pay all charges thereafter
What is not covered Treatment that is not authorized by a Plan doctor All charges if the member does not complete the treatment program
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Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan contracted or referral doctor and obtained at a Plan contracted pharmacy will be dispensed in accordance with the Plan's drug formulary for up to a
34 day supply You pay a 4 copay per prescription unit or refill Up to a 90 day supply of
drugs classified as maintenance by QualMed may be purchased through the Plan's mail order
drug program with an 8 copay per prescription unit or refill Drugs will be dispensed in
accordance with the Plan's drug formulary
QualMed Plans for Health uses a drug formulary Formulary is a list of commonly prescribed
covered medications that have been chosen by the Pharmacy and Therapeutics Committee based
on a drug's effectiveness and cost There are over 700 drugs on the Select Formulary This list
covers over 98 of all prescriptions written for QualMed members If a drug does not appear on
the formulary it is because there is another drug listed that works as well or better Nonformulary
drugs are not covered unless prior authorization is granted Only physicians may
call to receive authorization for a non formulary drug
Covered medications and accessories include
Drugs for which a prescription is required by Federal law Oral contraceptive drugs devices
Insulin with a copay charge applied to each vial Diabetes supplies including disposable insulin syringes needles glucose test tablets blood
glucose monitors monitor supplies insulin injection aids syringes insulin infusion
devices pharmacological agents for controlling blood sugar test tape Benedict's solution
or equivalent and acetone test tablets and orthodics are covered Medically necessary
equipment supplies and outpatient self management training and education including
medical nutrition therapy for the treatment of insulin dependent diabetes
Intravenous fluids and medication for home use implantable drugs and some injectable drugs are covered under Medical and Surgical Benefits covered under Medical and
Surgical Benefits as a home health service see page 11
Disposable needles and syringes needed for injecting covered prescribed medication
Limited Benefits Drugs to treat sexual dysfunction are limited Contact the Plan for dose limits You pay a 4 copay for up to the dose limit and all charges above that
What is not covered Drugs available without a prescription or for which there is a nonprescription equivalent available
Drugs prescribed by non contracted doctors except for out of area urgent emergent care Drugs obtained at a non Plan contracted pharmacy except for out of area urgent emergent
care
Medical supplies such as dressings and antiseptics Vitamins and nutritional substances which can be purchased without a prescription
Drugs for cosmetic purposes Drugs to enhance athletic performance
Smoking cessation drugs and medication including nicotine patches Implanted time release medications
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QualMed Plans for Health 2000
Other Benefits
Dental care
Accidental injury Restorative services and supplies necessary to promptly repair but not replace sound natural
benefit teeth 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 routine eye examinations including refractions once every calendar year for
members seventeen 17 years of age and under and once every two 2 calendar years for
members eighteen 18 years of age and older Members may self refer for routine eye
examinations and must obtain services from Plan contracted providers only You pay a 10
copay per visit
What is not covered Corrective eyeglasses and frames or contact lenses including the fitting of the lenses Eye exercises
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN CONTRACTED DOCTORS
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QualMed Plans for Health 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 the FEHB deductibles out of pocket maximum
copay charges etc These benefits are not subject to the FEHB disputed claims procedures
Health Care Information and Assistance
QualMed HealthLine Through QualMed's toll free HealthLine registered nurses are available to provide health care answers for members 24 hours a day every day of the year These skilled professionals use
their years of clinical experience and the extensive computerized medical resources at their
fingertips to assist members and direct them to the appropriate care
Health Newsline and Members can call a toll free number listen to more than 150 pre recorded health care topics
Resource Guide
Being Well Magazine Subscriber households receive Being Well QualMed's exclusive award winning magazine
Wellness Incentives
Fitness Reimbursement QualMed members receive up to 300 annual reimbursement for participation in cardiovascular programs at the fitness club of their choice QualMed has also arranged for fitness club
discounts at over 150 area fitness clubs Members can combine the discounted membership and
reimbursement for even greater savings
Weight Management QualMed members receive up to 200 annual reimbursement when they achieve and maintain
Reimbursement their goal weight by participating in a network hospital or other approved weight management program
Smoking Cessation QualMed Members can receive up to 200 annual reimbursement for participation in QualMed's
Reimbursement Committed Quitters Stop Smoking program which combines a nicotine replacement product with a personalized stop smoking plan Reimbursement is also available for smoking cessation
programs at participating hospitals
Women's Health Programs
Preventive Care QualMed members have direct access to routine gynecological exams without a PCP referral Members also receive mammography reminders on a regular basis
New Mom s Program QualMed offers members a free comprehensive maternity services program that includes valuable information concerning prenatal health health during pregnancy member benefits
money saving coupons and a free gift for the new mom and baby
Childbirth Class QualMed reimburses up to 85 when members attend and complete childbirth classes at
Reimbursement participating hospitals
Safety Programs
Bike Safety Program with QualMed offers free helmets to kids and teen members aged 4 18 who attend our free class on
Free Helmet bike safety basics with a parent or guardian
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QualMed Plans for Health 2000
Section 6 General Exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless
your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition
We do not cover the following
Services drugs or supplies that are not medcially necessary Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan doctors or hospitals 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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QualMed Plans for Health 2000
Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On
occasion you may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain
enrolled with us
If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a
Medicare Choice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a Medicare Choice plan contact your retirement office If
you later want to re enroll in the FEHB Program generally you may do so only at the next Open
Season
If you involuntarily lose coverage or move out of the Medicare Choice service area you may
re enroll in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and
your benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration
SSA office or request it from SSA at 1 800 638 6833 For information on the
Medicare Choice plan offered by this Plan call 1 800 326 0078
Other group insurance When anyone has coverage with us and with another group health plan it is called double
coverage coverage You must tell us if you or a family member has double coverage You must also send us documents about other insurance if we ask for them
When you have double coverage our plan is the primary payer it pays benefits first The other
plan is secondary it pay benefits next We decide which insurance is primary according to the
National Association of Insurance Commissioners Guidelines
If we pay second we will determine what the reasonable charge for the benefit should be After
the first plan pays we will pay either what is left of the reasonable charge or our regular benefit
whichever is less We will not pay more than the reasonable charge If we are the secondary
payer we may be entitled to receive payment from your primary plan
We will always provide you with the benefits described in this brochure Remember even if you
do not file a claim with your other plan you must still tell us that you have double coverage
Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to
beyond our control provide them In that case we will make all reasonable efforts to provide you with necessary care
When others are responsible When you receive money to compensate you for medical or hospital care for injuries or illness
for injuries that another person caused you must reimburse us for whatever services we paid for We will cover the cost of treatment that exceeds the amount you received in the settlement If you do not
seek damages you must agree to let us try This is called subrogation If you need more
information contact us for our subrogation procedures
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QualMed Plans for Health 2000
Section 7 Limitations Rules that affect your benefits cont
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover
you we are the primary payer See your TRICARE Health Benefits Advisor if you have
questions about TRICARE coverage
Workers Compensation We do not cover services that You need because of a workplace related disease or injury that the Office of Workers
Compensation Programs OWCP or a similar Federal or State agency determine they must
provide
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment we will
provide you benefits
Medicaid We pay first if both Medicaid and the Plan cover you
Other Government Agencies We do not cover services and supplies that a local State or Federal Government agency directly or indirectly pays for
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QualMed Plans for Health 2000
Section 8 FEHB Facts
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the
information about your right to information about your health plan its networks providers and facilities You can also
HMO find out about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational
OPM's website www opm gov lists the specific types of information that we must make
available to you
If you want specific information about us call 1 800 736 2096 or write to QualMed Plans for
Health 1835 Market Street 9 th Floor 11 Penn Center Philadelphia PA 19103 or visit our
website at www qualmed com
Where do I get information Your employing or retirement office can answer your questions and give you a Guide to Federal
about enrolling in the FEHB Employees Health Benefits Plans brochures for other plans and other materials you need to
Program make an informed decision about 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 and The benefits in this brochure are effective on January 1 If you are new to this plan your
premiums effective coverage and premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants premiums begin January 1
What happens when I retire When you retire you can usually stay in the FEHB Program Generally you must have been enrolled in the FEHB Program for the last five years of your Federal service If you do not meet
this requirement you may be eligible for other forms of coverage such as Temporary
Continuation of Coverage which is described later in this section
What types of coverage are Self Only coverage is for you alone Self and Family coverage is for you your spouse and your
available for my family and unmarried dependent children under age 22 including any foster or step children your employing
me or retirement office authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years of age or older who is incapable of self support
If you have a Self Only enrollment you may change to a Self and Family enrollment if you
marry give birth or add a child to your family You may change your enrollment 31 days before
to 60 days after you give birth or add the child to your family The benefits and premiums for
your Self and Family enrollment begin on the first day of the pay period in which the child is
born or becomes an eligible family member
Your employing or retirement office will not notify you when a family member is no longer
eligible to receive health benefits nor will we Please tell us immediately when you add or
remove family members from your coverage for any reason including divorce
If you or one of your family members is enrolled in one FEHB plan that person may not be
enrolled in another FEHB plan
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QualMed Plans for Health 2000
Section 8 FEHB Facts cont
Are my medical and We will keep your medical and claims information confidential Only the following will have
claims records access to it
confidential OPM this Plan and subcontractors when they administer this contract This plan and appropriate third parties such as other insurance plans and the Office of
Worker's Compensation Program OWCP when coordinating benefit payment 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 cliam 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 conditions We will not refuse to cover the treatment of a condition that you or a family member had before you enrolled in the 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 the 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 spouse If you are divorced from a Federal employee or annuitant you may not continue to get benefits
coverage under your former spouse's enrollment But you may be eligible for your own FEHB coverage under the spouse equity law If you are recently divorced or are anticipating a divorce contact
your ex spouse's employing or retirement office to get more information about you coverage
choices
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QualMed Plans for Health 2000
Section 8 FEHB Facts cont
When you lose benefits cont
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For
example you can receive TCC if you are not able to continue your FEHB enrollment after you
retire You may not elect TCC if you are fired from your Federal job due to gross misconduct
Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health
Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your
employing or retirement office
Key points about TCC
You can pick a new plan If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32 nd day after your regular coverage ends even if several months have
passed
You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll in TCC If you leave Federal service your employing office will notify you of your right to enroll under TCC You must enroll within 60 days of leaving or receiving this notice whichever is later
Children You must notify your employing or retirement office within 60 days after your
child is no longer an eligible family member That office will send you information about
enrolling in TCC You must enroll your child within 60 days after they become eligible for
TCC or receive this notice whichever is later
Former Spouses You or your former spouse must notify your employing or retirement
office within 60 days of one of these qualifying events
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 our or your former spouse
notify your employing or retirement office within the 60 day deadline
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QualMed Plans for Health 2000
Section 8 FEHB Facts cont
When you lose benefits cont
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 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 long 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
Certificate of Group that indicates how long you have been enrolled with us You can use this certificate when
Health Plan Coverage getting health insurance or other health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new plan must reduce or eliminate waiting periods
limitations or exclusions for health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in other
FEBH plans you may request a certificate from them as well
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QualMed Plans for Health 2000
Inspector General Advisory
Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for
services you did not receive billed you twice for the same service or misrepresented any information do the following
Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 1 800 736 2096 and explain the situation
If we do not resolve the issue call or write
THE HEALTH CARE FRAUD HOTLINE
202 418 3300
The 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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QualMed Plans for Health 2000
Notes
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QualMed Plans for Health 2000
Notes
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QualMed Plans for Health 2000
Summary of Benefits for QualMed Plans for Health Inc 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 CONTRACTED 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 12
Extended care All necessary services up to 120 days per calendar year You pay nothing 12
Mental conditions Diagnosis and treatment of acute psychiatric conditions for 30 days of inpatient care
per year You pay nothing 14
Substance abuse Up to 30 day per member per year for residential substance abuse treatment services in a licensed participating facility up to a lifetime maximum of 90 days
You pay nothing
during the benefit period all charges thereafter 15
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 5 copay per office visit 5 copay for house call by a
doctor 10
Home health care All necessary visits by nurses and health aides You pay nothing 10
Mental conditions Up to 20 outpatient visits per year up to 60 visits for serious mental illnesses You pay
nothing for the first 6 visits per year a 10 copayment per visit for visits 7 15 a 25
copayment per visit for visits 16 60 you pay all charges thereafter 14
Substance abuse Up to 20 outpatient visits per member per calendar year to a participating facility for
the treatment of substance abuse up to a lifetime maximum of 120 visits You pay
nothing during the benefit period all charges thereafter 15
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 13
Prescription Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 4
drugs copay up to a 34 day supply with a maximum of five 5 refills A 90 day supply of maintenance drugs may be purchased through the Plan's mail order Drug program You
pay a 8.00 copay per prescription unit or refill 15
Dental care Accidental injury benefit You pay nothing 16
Vision care Routine eye examinations including refractions once every calendar year for members seventeen 17 years of age and under and once every two 2 calendar years
for members eighteen 18 years of age and older Members may self refer for routine
eye examinations and must obtain services from Plan providers only You pay 5 16
Out of pocket Copayments are required for a few benefits However copayments will not be required
maximum for the remainder of the calendar year after your out of pocket expenses for services provided or arranged by the Plan reach 500 per member This copayment maximum
does not include costs of prescription drugs 6
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QualMed Plans for Health 2000
2000 Rate Information for
QualMed Plans for Health
FEHB Benefits of this Plan are described in brochure 73 40
The 2000 rates for this Plan follow Non Postal rates apply to most non Postal enrollees
If you are in a special enrollment category refer to an FEHB Guide or contact the agency that maintains
your health benefits enrollment Postal rates apply to all USPS career employees and do not apply to noncareer
Postal employees Postal retirees or associate members of any Postal employees organization
Non Postal Premium Postal Premium
Biweekly Monthly Biweekly
Type of Code Gov't Your Gov't Your USPS Your
Enrollment Share Share Share Share Share Share
Southern Pennsylvania New Jersey
Self Only 271 78.83 44.46 170.80 96.33 93.06 30.23
Self and Family 272 175.97 110.66 381.27 239.76 207.74 78.89
Scranton Wilkes Barre
Self Only 2K1 66.03 22.01 143.06 47.69 78.14 9.90
Self and Family 2K2 160.31 53.44 347.35 115.78 189.70 24.05
30 31