Pages 1--40 from Untitled

Serving Northern Virginia Maryland and Washington D C
Enrollment in this Plan is limited see page 5 for requirements

High Option
Enrollment code
E51 Self Only
E52 Self and Family

Special Notice The George Washington University Health Plan
Standard Option is no longer offered If you were enrolled in the
Standard Option Enrollment code E54 or E55 in 1999 and do
not enroll in another carrier's plan during Open Season your
enrollment will be automatically changed to The George
Washington University Health Plan High Option

Visit the OPM website at http www opm gov insure
and
our website at http www gwhealthplan com

Authorized for distribution by the
United States Office of
Personnel Management
Retirement and Insurance Service Federal Employees Health Benefits Program

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The George Washington University Health Plan 2000
Table of Contents

Page
Introduction 1

Plain language 1
How to use this brochure 2
Section 1 Health Maintenance Organizations 3
Section 2 How we change for 2000 3 4
Section 3 How to get benefits 5 10
Section 4 What to do if we deny your claim or request for service 11 12
Section 5 Benefits 13 25
Non FEHB Benefits Available to Plan Members 26
Section 6 General exclusions Things we don't cover 27
Section 7 Limitations Rules that affect your benefits 27 28
Section 8 FEHB FACTS 29 32
Inspector General Advisory Stop Healthcare Fraud 33
Summary of benefits Inside Back Cover
Premiums Back Cover

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The George Washington University Health Plan 2000
Introduction

The George Washington University Health Plan Inc
4550 Montgomery Avenue Suite 800
Bethesda MD 20814

This brochure describes the benefits you can receive from The George Washington University Health Plan under its contract
CS1764 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
pages 3 4 Premiums are listed at the end of this brochure

Plain Language
The President and Vice President are making the Government's communication more responsive accessible and understandable to
the public by requiring agencies to use plain language Health plan representatives and Office of Personnel Management staff
have worked cooperatively to make portions of this brochure clearer In it you will find common everyday words except for
necessary technical terms you and other personal pronouns active voice and short sentences

We refer to The George Washington University Health Plan Inc as this Plan or the Plan or we or us or our throughout
this brochure even though in other legal documents you will see a plan referred to as a carrier The use of the term our in
reference to a provider or facility i e doctor or hospital refers to persons facilities and other entities with whom this Plan has
contracted for services

These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more
understandable

We have not re written the Benefits section of this brochure You will find new benefits language next year

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The George Washington University Health Plan 2000
How to Use This Brochure

This brochure has eight sections Each section has important information you should read If you want to compare this Plan's
benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar information to
make comparisons easier

1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs
and how they work

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

5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find
information about non FEHB benefits

6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB FACTS Read this for information about the Federal Employees Health Benefits FEHB Program

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The George Washington University Health Plan 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 preventive 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 amounts 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

The George Washington University Health Plan Inc is a not for profit organization owned by The George Washington University The
Plan was organized under the District of Columbia Non Profit Corporation Act on May 16 1972

The Plan is licensed in three 3 jurisdictions the District of Columbia the State of Maryland and the Commonwealth of Virginia The
Plan renewed its health maintenance organization HMO licenses in Virginia on July 1 1998 in Maryland on December 1 1998 and
in the District of Columbia on April 15 1999 The Plan has been federally qualified since 1979 under the Federal HMO Act of 1973

Section 2 How We Change For 2000
Program wide changes To keep your premium as low as possible OPM has set a minimum copay of 10 for all 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 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 your health care provider does not give 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

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The George Washington University Health Plan 2000
Section 2 How We Change For 2000 continued

Changes to this Plan Your share of the non postal High Option premium will decrease by 28.4 for Self Only or 12.2 for Self and Family See Back Cover

The Standard Option will not be offered Only one option the High Option will be available
If you were enrolled in the Standard Option in 1999 and do not make an Open Season change
your enrollment will be automatically changed to the High Option

How the Plan changes The emergency room copayment increased from 30 to 50 per visit See page 18
from the former High The 90 day limit for cardiac rehabilitation has been removed See page 15
and Standard Options If a member does not select a primary care physician one will be chosen for him her

See page 6
You must contact the appropriate Plan Mental Health Administrator to obtain
precertification for mental health substance abuse treatment services See pages 9 and 20

A 5 sterilization fee for each dental office visit applies See page 24

How the Plan changes The copay increases from nothing to 10 for a primary care office visit and urgent care
from the former High center visits See page 13
Option Plan The copay increases from nothing to 10 for specialty care office visits including vision care allergy testing home health visits and for each MRI or CT scan See page 13

A Prescription Drug deductible is being added Each member must pay the first 35
of prescription expense i e deductible per calendar year See page 21

How the Plan changes The copayment decreased from 20 to 10 for specialty care office visits including vision
from the former care allergy testing and for each MRI or CT scan See page 13
Standard Option The copayments are being reduced from 150 to nothing for each hospital admission and
Plan for inpatient care for mental conditions See page 16

The copayment is being reduced from 50 to nothing for each outpatient surgery See
page 13

The copayment is being reduced from 20 to 10 for each home health visit See
page 13

The calendar year deductible is being reduced from 50 to 35 under the Prescription
Drug Benefits See page 21

The maximum out of pocket expense has been reduced from 1,000 to 650 per
calendar year for Self Only enrollment and from 2,500 to 1,500 per calendar year for
Self and Family enrollment See page 5

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The George Washington University Health Plan 2000
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
service area practice Our service area is

The District of Columbia the Virginia cities of Alexandria Fairfax Falls Church
Fredericksburg Manassas Manassas Park and Winchester as well as the Virginia counties of
Arlington Fairfax Fauquier Frederick Loudoun Prince William Spotsylvania Stafford and
Warren the Maryland city of Baltimore and the Maryland counties of Anne Arundel
Baltimore Calvert Carroll Cecil Charles Frederick Harford Howard Montgomery Prince
George's St Mary's and Washington

Ordinarily you must get your care from providers who contract with us If you receive care
outside our service area we will pay only for emergency care We will not pay for any other
health care services

If you or a covered family member move outside of our service area you can enroll in another
plan If your dependents live out of the area for example if your child goes to college in
another state you should consider enrolling in a fee for service plan or an HMO that has
agreements with affiliates in other areas If you or a family member move you do not have to
wait until Open Season to change plans Contact your employing or retirement office

How much do I pay You must share the cost of some services This is called either a copayment a set dollar
for services amount or coinsurance a set percentage of charges Please remember you must pay this amount when you receive services

NOTE Be sure to give adequate notice if you are unable to keep an appointment Plan
doctors may charge you 25 if you fail to keep your appointment or cancel with less than 24
hours notice

After you pay 650 in copayments or coinsurance for one family member or 1,500 for two or
more family members you do not have to make any further payments for certain services for
the rest of the year This is called your out of pocket maximum However copayments or
coinsurance for your prescription drugs dental services infertility treatment durable medical
equipment and orthopedic and prosthetic devices do not count toward this maximum 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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The George Washington University Health Plan 2000
Section 3 How To Get Benefits continued

Who provides my Your health care is provided by physicians and other participating providers in the service area
health care who are part of this Plan's independent network All of the physicians who participate in the network have been carefully screened and credentialed following strict standards

You and each of your family members must select a primary care physician Primary care
includes Family Practice Internal Medicine and Pediatrics physicians Each family member
can choose a different physician Your primary care physician is responsible for managing all
of your medical care Your physician refers you for specialty care and special services when
necessary and makes arrangements if you need to be hospitalized

NOTE If you select a primary care physician who is one of the GW Medical Faculty
Associates MFA physicians located at 2150 Pennsylvania Avenue NW Washington DC you
will be referred only to specialty providers who are part of the MFA If you select a GW MFA
primary care physician and you need to be hospitalized you will be admitted to The George
Washington University Hospital

If you would like more information about this Plan's doctors call the Member Services
Department at 301 941 2021

How do I choose a The Plan's Directory of Participating Providers lists primary care physicians Family Practice
primary care Internal Medicine and Pediatric physicians their locations phone numbers languages spoken
physician and whether or not the doctor is accepting new patients Generally if you are switching plans but keeping the same primary care physician you are not considered a new patient

Directories are available upon request by calling Member Services at 301 941 2021 They are
updated periodically new physicians are always joining the Plan and occasionally others leave
We cannot guarantee that any doctor hospital or other provider will remain available You can
call Member Services or the office of the physician you are interested in to verify whether a
particular physician still participates with this Plan

If you decide to enroll in this Plan you must choose a primary care physician for you and each
member of your family You can make your selection by filling out and mailing the
Physician Dentist Selection Form in your enrollment packet or by calling Member Services
Please note If you do not choose a primary care physician we will choose one for you

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The George Washington University Health Plan 2000
Section 3 How To Get Benefits continued

What if I want to You can either call Member Services at 301 941 2021 or write to us at this address
change my primary
care physician Attention Member Services The GW Health Plan

4550 Montgomery Avenue Suite 800
Bethesda MD 20814

If we receive your request by the 15 th of the month the change will become effective by the
first of the following month If we receive your request after the 15 th the change will become
effective the first of the month after the next month For example If we receive your request
on August 10 2000 the change will become effective on September 1 2000 if we receive
your request on August 16 2000 the change will become effective on October 1 2000 We
may make an exception to this policy under special circumstances

You must continue to use your current primary care physician until the change has become
effective If you receive medical care from the new doctor prior to the effective date of the
change the cost of that care will be your responsibility

How do I start a On your first visit to your primary care physician a medical record will be established for you
medical record If you are a new patient you will need to provide your medical history It is best to transfer
or transfer one your medical record from your former physician to your new physician's office before your first visit

To transfer your medical record you can fill out a Medical Record Release Form and send it to
your former physician's office or just call the former physician's office and ask them to send
the record to your new physician The physician is allowed to charge a fee for photocopying
your record

Can I review my You have the right to review your medical record or get a copy at any time You also have the
medical record right to request that a physician amend i e change delete from or add to your medical record if it is not accurate relevant or complete If the physician does not agree to amend the

record you may add a brief statement to the record Whenever your medical record is shown
or transferred your statement must be included If you have difficulty obtaining medical
records from a provider call Member Services at 301 941 2021 for assistance

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 This includes admission to a skilled nursing facility or other alternative care center

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The George Washington University Health Plan 2000
Section 3 How To Get Benefits continued

What do I do if I'm First call us immediately or have someone call for you If you are new to the FEHB Program
in the hospital when we will arrange for you to receive care If you are currently in the FEHB Program and are
I join this Plan 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 Your primary care physician will arrange your referral to a specialist You must always be
specialty care referred by your primary care physician before consulting a specialist or getting any specialized services EXCEPT in the following cases

In an emergency
For gynecological or obstetrical care including annual checkups
For your annual routine eye examination
When your primary care doctor has assigned another doctor the doctor on call to
take care of patients because he she is not available

When you have already received a referral authorizing long term treatment

When your primary care physician refers you you must take the referral form with you to your
specialist appointment Your physician will write specific instructions on the form about what
services you can receive and how many times you may visit the specialist If the specialist
suggests additional services or visits are needed you must first check with your primary care
physician to obtain another referral

If you need to see a specialist frequently because of a chronic complex or serious medical
condition your primary care physician with your specialist and our Medical Management
Department will develop a treatment plan that allows you to see your specialist for a certain
number of visits without additional referrals Examples of chronic complex or serious medical
conditions would be kidney failure cancer or diabetes

What do I do if I First visit or call the primary care physician you selected under this Plan Your primary care
am seeing a specialist physician will decide whether you need to continue seeing a specialist Even if you selected
when I enroll the same primary care physician you had before you enrolled in this Plan you must be referred by the primary care physician to continue specialty care under this Plan

If the specialist you are already using 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 Call your primary care physician who will arrange for you to see another specialist You may
specialist leaves the receive approval to obtain services from your current specialist until we can make
Plan arrangements for another specialist to treat you

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The George Washington University Health Plan 2000
Section 3 How To Get Benefits continued

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 Plan contract with the provider unless the termination is for cause If you are in the second or
or this Plan leaves the third trimester of pregnancy you may continue to see your OB GYN until the end of your
FEHB Program postpartum care

You may also be able to continue seeing your current provider if this Plan should drop out of
the FEHB Program and you enroll in a new FEHB plan Contact the new plan and explain that
you have a serious or chronic condition or are in your second or third trimester of pregnancy
Your new plan will pay for or provide your care for up to 90 days after you receive notice that
your prior plan is leaving the FEHB Program If you are in your second or third trimester of
pregnancy your new plan will pay for the OB GYN care you receive from your current
provider until the end of your postpartum care

How do you authorize Your primary care physician has the authority to refer you for many services For certain
medical services services however your physician must obtain approval from us Before giving approval we consider if the service is medically necessary if it follows generally accepted medical practice

and if it is a covered service

This review and approval process is also called precertification Your physician must obtain
precertification for the following services

Any inpatient hospital admission
Any inpatient or outpatient surgical procedure
Physical occupational speech or cardiac therapy
Inpatient skilled nursing care in a facility
MRIs or CT scans
Infertility treatment or procedures
Durable medical equipment and supplies purchase and rental
Home health services
Hospice care

EXCEPTION A Mental Health Administrator must precertify all mental health substance
abuse treatment services You must call the Mental Health Administrator at 1 888 571 0213
before you contact a mental health or substance abuse treatment provider

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The George Washington University Health Plan 2000
Section 3 How To Get Benefits continued

How do you decide if a The Plan's Medical Director determines what products procedures services and supplies are
service is experimental experimental or investigational in accordance with generally accepted medical practice
or investigational Experimental and investigational products procedures services and supplies include those which are 1 in a testing stage or in field trials on animals or human beings 2 have not

received the required final federal regulatory approval for commercial distribution for the
specific purposes and methods of use 3 with respect to prescription drugs have not been
approved by the U S Food and Drug Administration as safe and effective treatment for the
member's particular illness or condition except as described below 4 are not in accordance
with generally accepted standards of medical practice or 5 have not yet been shown to be
consistently effective in diagnosing or treating the member's condition

A committee made up of community physicians Plan staff and experts in the field will
review published literature and other presentations to make an informed decision regarding
the effectiveness of the service It is considered investigational if it is not yet being used in a
clinical trial It is considered experimental if it has moved from investigational to the clinical
trial state where numbers of humans have been identified and agreed to participate in the
experimental use of the service or treatment

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

What if I have a serious Call us at 301 941 2021 and we will expedite our review
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
denied my request for inform OPM so that they can give your claim expedited treatment too Alternatively you can
care and my condition call OPM's health benefits Contract Division 3 at 202 606 0755 between 8 a m and 5 p m
is serious or life Monday through Friday
threatening

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

1 We did not answer your request within 30 days In this case OPM must receive your
request within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we 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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The George Washington University Health Plan 2000
Section 4 What To Do If We Deny Your Claim Or Request For Service continued

What do I send to You must send the following information
OPM 1 A statement about why you believe our decision is wrong based on specific benefit

provisions in this brochure
2 Copies of documents that support your claim such as physicians letters operative
reports bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim
4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call

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

Who can make the Those who have a legal right to file a disputed claim with OPM are
request 1 Anyone enrolled in the Plan

2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the
enrolled person's representative They must send a copy of the person's specific written
consent with the review request

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

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 Federal law governs your lawsuit benefits and payment of benefits The Federal court will
I file a lawsuit base 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
Privacy Act you 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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The George Washington University Health Plan 2000
Section 5 Benefits

Medical and Surgical Benefits
What is covered The Plan covers a comprehensive range of preventive diagnostic and treatment services when provided by Plan doctors and other Plan providers This includes all necessary office visits
You pay a 10 copayment for office visits to your primary care physician You pay a 10
copayment for office visits to a specialist for home health visits allergy testing and for each
MRI or CT scan you receive You pay nothing for laboratory tests X rays prenatal care
visits well child visits through age 6 or for outpatient surgery performed at a hospital or
ambulatory care center

The following services are included
Preventive care including well baby care and periodic check ups
Routine immunizations and boosters
Diagnostic procedures such as laboratory tests and X rays
Consultations by specialists if referred by your Plan primary care physician
Allergy testing and treatment including test and treatment materials such as
allergy serum

Self referral to Plan doctors for gynecological care You pay a 10 office visit copayment
for your annual gynecological well woman examination and a 10 office visit
copayment for all other gynecological visits

Self referral to Plan doctors for obstetrical maternity care Women may use Plan
certified nurse midwives under the supervision of a Plan doctor or other qualified provider
You pay nothing for prenatal or postnatal care visits after the first visit

Self referral to Plan doctors for annual routine eye examination You pay a 10 office
visit copayment

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 physician as medically
necessary to diagnose your illness

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 an uncomplicated regular delivery and 96 hours after a cesarean
delivery Inpatient stays will be extended if medically necessary If enrollment in the Plan
is terminated during pregnancy benefits will not be provided after coverage under the Plan
has ended Ordinary nursery care of the newborn child during the covered portion of the
mother's 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 when the infant is covered under a Self and Family enrollment

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CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 15
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The George Washington University Health Plan 2000
Section 5 Benefits continued

What is covered Voluntary sterilization and family planning services
continued Diagnosis and treatment of diseases of the eye

The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart lung single and double lung pancreas pancreas kidney kidney and
liver transplants allogeneic donor bone marrow transplants autologous bone marrow
transplants autologous stem cell and peripheral stem cell support for the following
conditions acute lymphocytic or non lymphocytic leukemia advanced Hodgkin's
lymphoma advanced non Hodgkin's lymphoma advanced neuroblastoma breast cancer
multiple myeloma epithelial ovarian cancer and testicular mediastinal retroperitoneal
and ovarian germ cell tumors subject to approval by the Plan's Medical director Related
medical and hospital expenses of the donor are covered when the recipient is covered by
this Plan

Women who undergo mastectomies may at their option have this procedure performed
on an inpatient basis and remain in the hospital up to 48 hours after the procedure

Dialysis
Chemotherapy radiation therapy and inhalation therapy
Podiatry services related to underlying medical conditions e g diabetic foot problems
Surgical treatment of morbid obesity
Blood products and blood derivatives
Home health services including nurses intravenous fluids and medications when
prescribed by a Plan doctor The doctor will periodically review the need for
continued services

Medically necessary medical or surgical care in a hospital or extended care facility
provided by Plan doctors and other contracted providers

Limited benefits Oral and maxillofacial surgery is provided for non dental related 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 temperomandibular joint TMJ pain dysfunction syndrome
except as covered under Dental Benefits See pages 23 25

Reconstructive surgery will be provided to correct a condition resulting from a functional
defect from an injury or surgery that has produced a major effect on the member's appearance
and only if the condition can reasonably be expected to be corrected by such surgery A patient
and her attending physician may decide whether she should 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 90 days per condition if significant improvement can be
expected within 90 days 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 Treatment
is limited to one session per day You pay a 10 copayment per outpatient session

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CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 16
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The George Washington University Health Plan 2000
Section 5 Benefits continued

Limited benefits Cardiac rehabilitation following a heart transplant bypass surgery myocardial infarction
continued You pay a 10 copayment per outpatient session

Durable medical equipment DME is defined as equipment which must be able to
withstand repeated use primarily serve a medical purpose and be appropriate for use in your
home DME includes items such as non motorized wheelchairs hospital beds oxygen
equipment and oxygen for home use orthopedic devices such as braces crutches and canes
and prosthetic devices such as artificial limbs and ocular lenses following cataract removal
Repair and replacement of prosthetic and orthopedic devices will be provided only when
growth necessitates replacement limited to one replacement only Repairing replacing and
duplicating DME items are not covered For a list of specific covered items call Member
Services at 301 941 2021 The purchase or rental of DME must be precertified through the
Plan's Medical Management Department You pay the first 100 expense per member per year
plus 50 of the remaining expense Your expenses for durable medical equipment orthopedic
devices and prosthetic devices do not count toward your out of pocket maximum

Breast prostheses and surgical bras and their replacements are covered subject to applicable
DME deductible and copayments

Diagnosis and certain treatments of infertility are covered You pay 50 of the cost of
treatment Copayments for infertility do not count toward your out of pocket maximum Cost
of donor sperm is not covered The following types of artificial insemination are covered
intravaginal insemination IVI intracervical insemination ICI and intrauterine insemination
IUI Other assisted reproductive technology ART procedures are not covered Fertility
drugs are not covered

Chiropractic services are provided for up to 20 visits per condition per calendar year if
significant improvement can be expected within 20 visits You pay an 8 copayment for the
first five visits a 14 copayment for the 6 th through 20 th visits and a 20 copayment for all
visits thereafter The 20 copayment will be applicable only if the member has had two or
more conditions during the calendar year and has already received a combined total of 20
chiropractic visits during the calendar year

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

Immunizations for travel
Devices available without a prescription or for which there is a nonprescription
equivalent available

Reversal of voluntary surgically induced sterility
Surgery primarily for cosmetic improvements
Hearing aids
Wigs and other hair prostheses
Eyewear frames contact lenses and the fitting of contact lenses
Homemaker services
Orthotic devices and specified DME items not covered by this Plan

15
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 17
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The George Washington University Health Plan 2000
Section 5 Benefits continued

What is not covered Whole blood and concentrated red blood cells
continued Organ transplants not listed as covered

Long term habilitative and rehabilitative therapy
Biofeedback
Sleep therapy
Radial Keratotomy LASIK surgery other vision correction surgeries and visual
training exercises

Routine podiatry services
Acupuncture naturopathy and hypnotherapy
Medical food nutritional substances tube and enteral feedings except intravenous
hyperalimentation

Motorized wheelchairs and carts

Hospital Benefits
What is covered 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 medically necessary services are covered including
Semiprivate room accommodations when Plan doctor determines it is medically
necessary the doctor may prescribe private accommodations or private duty nursing care

Specialized care units such as intensive care or cardiac care units

Extended Care The Plan provides a comprehensive range of benefits for up to 90 days per calendar year when full time skilled nursing care is medically necessary and confinement in a skilled nursing
facility is medically appropriate as determined by a Plan doctor and approved by the Plan
You pay nothing

All necessary services are covered including
Bed board and general nursing care
Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled
nursing facility when prescribed by a Plan doctor

16
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The George Washington University Health Plan 2000
Section 5 Benefits continued

Hospice care Supportive care and care to manage symptoms of a terminally ill member are 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 the
patient is in the terminal stages of illness with a life expectancy of approximately six months
or less You pay nothing

Ambulance service Benefits are provided for ground ambulance transportation ordered or authorized by a Plan doctor

Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when your primary care physician
procedures determines there is a need for hospitalization for reasons totally unrelated to the dental procedure The Plan will cover the hospitalization but not the cost of the professional dental

services Conditions for which hospitalization would be covered include hemophilia and heart
disease The need for anesthesia by itself is not such a condition

Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care
detoxification diagnosis treatment of medical conditions and medical management of withdrawal symptoms acute detoxification if the Plan physician determines that outpatient management is not

medically appropriate See page 21 for non medical substance abuse benefits
What is not covered Personal comfort items such as telephone and television
Whole blood and concentrated red blood cells
Custodial care rest cures domiciliary or convalescent care

17
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 19
19 Page 20 21
The George Washington University Health Plan 2000
Section 5 Benefits continued

Emergency Benefits
What is a medical A medical emergency is the sudden and unexpected onset of medical symptoms or an injury
emergency that you believe endangers your life or could result in serious injury or disability and therefore 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

This Plan offers a nurse triage telephone service Triage is the prioritization of medical
treatment This service can help you by advising you 1 whether you need to go to the
emergency room 2 whether your doctor can best treat your particular medical problem or 3
how to take care of minor injuries and illnesses yourself The nurse triage service can be
reached toll free at 1 800 667 2571

Emergencies within If you are in an emergency situation please call 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 they can notify the Plan You or
a family member must notify the Plan within 24 hours unless it is not reasonably possible to
do so It is your responsibility to ensure that the Plan is notified promptly

If you need to be hospitalized due to the emergency you must notify the Plan's Medical
Management Department within 24 hours or on the first business day following your
admission unless it is not reasonably possible to notify the Plan within that time The phone
number for the Medical Management Department is 301 941 2023 If you are hospitalized in
a non Plan facility and a Plan doctor believes care can be better provided in a Plan hospital
you will be transferred when medically feasible and any ambulance charges will be covered
in full

Benefits are available for care from non Plan providers in a medical emergency only if you
believe a delay in reaching a Plan provider could 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 For emergency care services to the extent such services are covered benefits of this Plan you pay a 50 copayment per visit to a hospital emergency room This copayment does not apply
if the emergency results in admission to the hospital
You pay a 10 copayment per visit to a primary care physician's office or urgent care center
You pay a 10 copayment to visit a specialist or for each MRI or CT scan You pay nothing
for outpatient surgery If the emergency results in admission to the hospital you pay nothing

Copayments apply even if the Plan doctor has authorized the emergency service 18 20
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The George Washington University Health Plan 2000
Section 5 Benefits continued

Emergencies outside Benefits are available for medically necessary health services that are immediately required
the service area because of injury or unforeseen illness

If you need to be hospitalized the Plan's Medical Management Department must be notified
within 24 hours or on the first business day following your admission unless it is not
reasonably possible to notify the Plan within that time The toll free number for the Medical
Management Department is 1 800 333 4947 If a Plan doctor believes care can be better
provided in a Plan hospital you will be transferred when medically feasible and any
ambulance charges will be 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 For emergency care services to the extent such services are covered benefits of this Plan you pay a 50 copayment per visit to a hospital emergency room This copayment does not apply
if the emergency results in admission to the hospital
You pay a 10 copayment per visit to a primary care physician's office or urgent care center
You pay a 10 copayment to visit a specialist or for each MRI or CT scan You pay nothing
for outpatient surgery If an emergency results in admission to the hospital you pay nothing

What is covered Emergency care at a physician's office or an urgent care center
Emergency care as an outpatient or inpatient including physicians services
Ground ambulance service when approved by the Plan

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

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

Cost of medical evacuation from any foreign country or distant areas of the United States
Members who wish to protect themselves from this expense are advised to purchase
travel insurance

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 receipt

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 procedure described
in Section 4 of this brochure 19 21
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The George Washington University Health Plan 2000
Section 5 Benefits continued

Mental Conditions Substance Abuse Benefits
Mental Conditions
What is covered To the extent shown below the Plan provides the following medically necessary services for the diagnosis and treatment of acute psychiatric conditions including the treatment of mental
illness or disorders
Diagnostic evaluation
Psychological testing that is medically necessary to determine the appropriate treatment of
a short term psychiatric condition

Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services

You must get precertification from the Mental Health Administrator before you contact a
mental health provider See How do you authorize medical services on page 9 The Mental
Health Administrator will precertify your treatment if it is medically necessary Call
1 888 571 0213 to request precertification

Outpatient care You pay a 20 copayment for each individual therapy session and a 10 copayment for each group therapy session for the treatment of Mental Conditions

Inpatient care Inpatient confinements are covered when determined to be medically appropriate and approved by the Mental Health Administrator You pay nothing
What is not covered Care for psychiatric conditions that in the professional judgment of the Mental Health Administrator are not subject to significant improvement through relatively short term
treatment
Psychiatric evaluation or therapy ordered by a court or as a condition of parole
or probation

Psychological testing e g neuro psychiatric testing to determine the appropriate
treatment of a short term psychiatric condition

20
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The George Washington University Health Plan 2000
Section 5 Benefits continued

Substance Abuse
What is covered This Plan covers 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 Outpatient visits to participating mental
health substance abuse treatment providers for follow up care and counseling are covered as
well as medically necessary inpatient services for diagnosis and treatment

Outpatient care You pay a 10 copayment for each therapy session for the treatment of Substance Abuse
Inpatient care Inpatient confinements are covered when determined to be medically appropriate and approved by the Mental Health Administrator You pay nothing

What is not covered Treatment that is not authorized by the Mental Health Administrator
Long term rehabilitative services for the treatment of alcoholism and or drug abuse including
prolonged rehabilitation services in a specialized inpatient or residential facility

Prescription Drug Benefits
What is covered Prescription drugs are covered when obtained at Plan pharmacies and prescribed by Plan doctors in accordance with the Plan's formulary A formulary is a list of medications that have
been reviewed and approved by the Plan to be included for coverage Formulary medications
are chosen based on their effectiveness in treating certain conditions and on other criteria

The Plan's Formulary Formulary drugs are divided into two categories Preferred and non preferred drugs The preferred drugs category includes generic drugs and brand name drugs Your prescription will
always be filled with a generic drug when one is available Preferred drugs should be
prescribed whenever they are appropriate in treating your illness or injury

Non preferred and non formulary drugs will be covered when prescribed by a Plan doctor
Your doctor is expected to request an exception to prescribe non preferred and non formulary
drugs Such requests must be submitted in writing by your doctor to the Plan's Pharmacy
Director prior to giving you a prescription Upon approval by the Plan such exceptions are
good for the current calendar year or a specified time period whichever is less Medical
justification for the drug is required

The formulary changes periodically based on findings of the Plan's Pharmacy and Therapeutics
P T Committee The P T Committee comprised of Plan doctors and pharmacists meets
quarterly to review the clinical quality and economic attributes of medications Members may
inquire whether a drug is included in the formulary by requesting a list from the Member
Services Department

21
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The George Washington University Health Plan 2000
Section 5 Benefits continued

Prescription Units Prescription drugs are dispensed in prescription units or refills One prescription unit or refill is
and Costs defined as up to a 30 day supply Drugs for maintenance purposes can be dispensed for up to a 90 day supply Maintenance drugs are those which your physician anticipates will be

required for at least six 6 months to treat a chronic condition such as hypertension or
diabetes

You and each family member pay the first 35 of prescription drug expense per year then
for each prescription unit or refill you pay the copayment according to the schedule below

You pay a 5 copayment for a generic drug
You pay a 15 copayment for a preferred brand name drug on the formulary
You pay a 25 copayment for a non preferred and or non formulary drug
You pay two copayments for up to a 90 day supply of maintenance drugs

In no event will the copayment exceed the cost for the prescription drug

Mail order Prescription Prescription drugs for maintenance purposes are dispensed in up to a 90 day supply through
Program the Mail order program For further information contact Member Services

You pay two copayments for up to a 90 day supply of maintenance drugs

Out of the Area If you need to fill a prescription when outside of our service area you can go to one of our Plan national pharmacies Call 1 800 237 6184 to find the nearest Plan pharmacy You'll pay
only your usual copayment and or deductible If a Plan pharmacy is not accessible while you
are out of the service area you will need to pay for your drugs and save the receipt You are
responsible for the difference in cost between drugs obtained from a Plan pharmacy and those
obtained from a non Plan pharmacy Be sure to keep all receipts and information describing
the drug the cost the prescribing physician and the date purchased Submit all requests for
reimbursement within 60 days For information about how to request reimbursement for your
prescription drugs call Member Services

Covered medications and accessories include
FDAapproved drugs for which a prescription is required by federal or state law
Contraceptive drugs oral injectible and implantable and devices IUDs diaphragms
approved by the FDAfor use as contraceptives

Insulin
Chemotherapy drugs
Disposable needles and syringes needed to inject covered prescribed medication

Limited benefits Diabetic supplies including glucometer supplies for insulin dependent diabetics and other medically qualified members are covered only when purchased in accordance with
Plan conditions and limitations
Growth hormones are covered only when medically necessary and appropriate to treat
an illness and if authorized as part of a treatment plan provided to and approved by the
Plan Medical Management Department

Sexual dysfunction drugs and some other drugs have dispensing limitations Contact the 22
Plan for details

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 24
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The George Washington University Health Plan 2000
Section 5 Benefits continued

What is not covered Drugs available without a prescription or for which there is a non prescription equivalent available

Drugs obtained at a non Plan pharmacy except when due to an emergency occurring
outside of the service area

Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Smoking cessation drugs and medication including nicotine patches
Drugs for cosmetic purposes
Drugs to enhance athletic performance
Drugs for infertility
Drugs to induce weight loss anorexients

Other Benefits
Dental Care
What is covered

Accidental injury Restorative services and supplies necessary to promptly repair sound natural teeth are covered
benefit The need for these services must result from an accidental injury Replacement of teeth lost as a result of injury is not covered You pay a copayment for the services of a dentist and 50 if

you are treated in the emergency room

Preventive and This Plan includes comprehensive dental care services when provided by Plan dentists The
Restorative Dental emphasis is on prevention with most preventive and diagnostic dental services covered with
Plan no copayment Copayments and fees are due at the time of service

You must select a primary care dentist from a list of participating dentists who provide general
dental care for you and your family All care must be provided by or through your primary
care dentist Your primary care dentist will provide referrals to participating dental specialists
when necessary To select a primary care dentist complete and send the Physician Dentist
Selection Form included in your enrollment packet All family members must select the same
primary care dentist

Out of area coverage is limited to services for the emergency relief of dental pain swelling or
other urgent conditions not related to accidental injury and is subject to a maximum
reimbursement of 50

23
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The George Washington University Health Plan 2000
Section 5 Benefits continued

Dental Service The list below is a partial list of the procedures covered under our Dental Plan with applicable
Copayments copayments You can obtain a complete list by calling 301 986 5600

NOTE Dentists may charge a 5 instrument sterilization fee at each office visit Copayments
and fees are due at the time of service

Diagnostic services
Initial and periodic oral exams Nothing
All X rays Nothing
Preventive services
Prophylaxis cleaning of teeth every six months Nothing
Prophylaxis each additional within six month 49
Topical fluoride treatment Nothing
Oral Hygiene instruction Nothing
Restorative services
All fillings silver composite 17 40
Inlay Onlay metallic 110 190
Crown bridge services
Crowns porcelain to full cast 290 315
Recement crown or inlay 10
Endodontic services
Root canal treatment 220 350
Pulpal therapy 10 30
Oral surgery services
Removal of tooth simple 39
Removal of tooth surgical 40 135
Surgical treatment for minor pathological problems Up to 125
Periodontal services
Curettage and root planing per quadrant 95
Periodontal surgery per quadrant 270 455
Occlusal bite adjustments 35 105
Prosthetic services
Dentures complete upper or lower 375
Partial dentures 285 420
Denture adjustments 10
Denture relining 45 65
Orthodontic services
Standard fully banded case
Child under 19 years 1,700
Adults 2,450

You pay a 25 charge for broken and no show appointments if less than 24 hours
notice to cancel is given

You pay a 25 surcharge for emergency after hours visits

24
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The George Washington University Health Plan 2000
Section 5 Benefits continued

What is not covered The following is a summary list of services which are not covered under Dental Care Benefits
Procedures for cosmetic purposes
Services and procedures not performed in a dentist's office when needed as a result of
injury and occurring outside of the service area

Dental procedures involving treatment of congenital malformations
Replacement of dentures or bridgework previously provided
Dental implants
Other dental services not specifically detailed as a covered service

Vision Care
What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye an annual routine eye examination refraction may be obtained from
participating providers You pay a 10 copayment per exam

What is not covered Eyewear frames contact lenses including special contact lenses used in the treatment
of certain eye diseases and their fitting

Eye exercises
Radial Keratotomy LASIK surgery and other vision correction surgeries
Visual training exercises

25
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 27
27 Page 28 29
The George Washington University Health Plan 2000
Non FEHB Benefits Available to Plan Members

The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are
made available to all enrollees and family members who are members of this Plan The cost of the benefits described on
this page is not included in the FEHB premium any charges for these services do not count toward any FEHB deductibles
out of pocket maximum copayment charges etc These benefits are not subject to the FEHB disputed claims procedures

Vision discounts Members may obtain discounts on the purchase of eyeglasses contact lenses and certain other non covered services when obtained through participating optometrists and opticians A list of
participating optometrists and opticians is located in the Directory of Participating Providers
Discounted Members are eligible for discounted membership fees for a variety of health and fitness clubs
membership fees located throughout the metropolitan area You do not pay any additional premium for this
at fitness centers service You pay the discounted membership fee directly to the fitness center Call Member Services at 301 941 2021 for a list of participating centers

Health information The Plan is pleased to offer FEHB members the following services
GW Vital Signs Member Newsletter A quarterly publication designed to keep members
informed about health issues and Plan news

Next Generation Babies Program A free program to help expectant mothers deliver
healthy full term babies Each participant who registers by the 16 th week of pregnancy
receives a welcome package and risk assessment Women with high risk pregnancies are
assigned to a Case Manager who works with her and her doctor Each woman who
completes 10 prenatal visits and a six week postnatal visit to her obstetrician receives a
valuable gift for herself and her baby To register call 1 888 366 2229

Disease Education and Health Education Services Education by telephone
regarding various diseases referrals to community resources for information
and assistance classes and programs are provided free to members
by calling 301 941 2160

Disease Management Services Assistance in learning about certain diseases in how to
control the symptoms and in doing so to improve or maintain quality of life Examples
are programs in Asthma Diabetes Congestive Heart Failure and High Blood Pressure
Management

The GW Health Plan gives you access to services at The George Washington University
Discounts at The Medical Center Center for Integrative Medicine GWUMC CIM The GWUMC CIM is

GWUMC Center for staffed by highly trained practitioners who offer programs in alternative and complementary
Integrative Medicine medicine including acupuncture body work guided imagery massage therapy and more These services are not covered under your contract but if you wish to use them yourself you

will receive a 20 percent discount off the normal full charge for each service at the
GWUMC CIM

Benefits on this page are not part of the FEHB Contract

26 28
28 Page 29 30
The George Washington University Health Plan 2000
Section 6 General Exclusions Things We Don't Cover

The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless
your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition

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

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

Section 7 Limitations Rules That Affect Your Benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the
payments On occasion you may need to file a Medicare claim form

If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain
enrolled with us

If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a
Medicare Choice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a Medicare Choice plan contact your retirement office If
you later want to re enroll in the FEHB Program generally you may do so only at the next
Open Season

If you involuntarily lose coverage or move out of the Medicare Choice service area you may
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 SSAat 1 800 638 6833

27 29
29 Page 30 31
The George Washington University Health Plan 2000
Section 7 Limitations Rules That Affect Your Benefits continued

Other group When anyone has coverage with us and with another group health plan it is called double
insurance coverage coverage You must tell us if you or a family member has double coverage You must also send us documents about other insurance if we ask for them

When you have double coverage one plan is the primary payer it pays benefits first The
other plan is secondary it pays benefits next We decide which insurance is primary according
to the National Association of Insurance Commissioners NAIC 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 the necessary care

When others are When you receive money to compensate you for medical or hospital care for injuries or illness
responsible 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

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

Workers compensation We do not cover services that
You need because of a workplace related disease or injury that the Office of Workers
Compensation Programs OWCP or a similar Federal or State agency determine they
must provide

OWCP or a similar agency pays for through a third party injury settlement or other
similar proceeding that is based on a claim you filed under OWCP or similar laws

Once the OWCP or similar agency has paid its maximum benefits for your treatment we will
provide your benefits

Medicaid We pay first if both Medicaid and this Plan cover you
Other Government We do not cover services and supplies that a local State or Federal Government agency
Agencies directly or indirectly pays for

28 30
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The George Washington University Health Plan 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
information about the right to information about your health plan its networks providers and facilities You can
your HMO also 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 301 941 2021 or write to Attn Member
Services GW Health Plan 4550 Montgomery Avenue Suite 800 Bethesda MD 20814 You
may also contact us by fax at 301 941 2093 or visit our website at www gwhealthplan com

Where do I get Your employing or retirement office can answer your questions and give you a Guide to
information about Federal Employees Health Benefits Plans brochures for other plans and other materials you
enrolling in the need to make an informed decision about
FEHB Program When you may change your enrollment

How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter
military service or retire

When your enrollment ends and
The next Open Season for enrollment

We don't determine who is eligible for coverage and in most cases cannot change your
enrollment status without information from your employing or retirement office

When are my benefits The benefits in this brochure are effective on January 1 If you are new to this plan your
and premiums coverage and premiums begin on the first day of your first pay period that starts on or after
effective January 1 Annuitants premiums begin January 1

What happens When you retire you can usually stay in the FEHB Program Generally you must have been
when I retire enrolled in the FEHB Program for the last five years of your Federal service If you do not meet this requirement you may be eligible for other forms of coverage such as Temporary

Continuation of Coverage which is described later in this section

What types of coverage Self Only coverage is for you alone Self and Family coverage is for you your spouse and
are available for my your unmarried dependent children under age 22 including any foster or step children your
family and me employing 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 marry 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 29
not be enrolled in another FEHB plan 31
31 Page 32 33
The George Washington University Health Plan 2000
Section 8 FEHB FACTS continued

Are my medical We will keep your medical and claims information confidential Only the following will have
and claims records access to it
confidential OPM this Plan and subcontractors when they administer this contract

This plan and appropriate third parties such as other insurance plans and the Office of
Workers Compensation Programs OWCP when coordination benefit payments and
subrogating claims

Law enforcement officials when investigating and or prosecuting alleged civil or
criminal actions

OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your
identity or

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

Information for new members
Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You
can also use an Employee Express confirmation letter
When you receive your ID card look it over carefully If it contains any incorrect information
call the Member Services Department immediately to request a new one When you receive
the new card destroy the old one If your card is lost or stolen call our Member Services
Department to request a replacement

You should carry your ID card with you at all times You will need to show it whenever you
receive services from a participating provider You also will need it whenever you get a
prescription filled at a participating pharmacy

Never let anyone else use your identification card

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
conditions before you enrolled in this Plan solely because you had the condition before you enrolled

30 32
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The George Washington University Health Plan 2000
Section 8 FEHB FACTS continued

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

You may be eligible for former spouse coverage or Temporary Continuation of Coverage

What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits
spouse coverage under your former spouse's enrollment But you may be eligible for your own FEHB coverage under the spouse equity law If you are recently divorced or are anticipating a

divorce contact your ex spouse's employing or retirement office to get more information about
your coverage choices

What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC
For example you can receive TCC if you are not able to continue your FEHB enrollment after
you retire You may not elect TCC if you are fired from your Federal job due to gross
misconduct Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal
Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse
Enrollees from your employing or retirement office

Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay
premiums from the 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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The George Washington University Health Plan 2000
Section 8 FEHB FACTS continued

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 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
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 FEHB plans you may request a certificate from them as well

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The George Washington University Health Plan 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 the Plan's Fraud and Abuse Hotline at 301 907 3515 or e mail to
audit comp vpt gwu edu 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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Notes
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Notes
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Notes
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The George Washington University Health Plan 2000
Summary of Benefits for The George Washington University Health Plan 2000

Do not rely on this chart alone All covered benefits are provided in full unless otherwise indicated subject to the limitations and
exclusions set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you wish to
enroll or change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear
on the cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE EXCEPTION OF
EMERGENCY CARE ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS

Benefits Plan pays provides Page
Inpatient Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes
Care in hospital doctor care room and board general nursing care semi 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 16
Extended Care All necessary services up to 90 days per calendar year You pay nothing 16
Mental Conditions Diagnosis and treatment of acute psychiatric conditions You pay nothing 20

Substance Abuse Medically necessary medical and hospital services including acute detoxification services
You pay nothing 21

Outpatient Care Comprehensive range of services such as diagnosis and treatment of illness or injury preventive care including well baby care and well child visits through age 6 periodic check ups and routine

immunizations complete maternity care specialty care visits MRI or CT scan laboratory tests and
X rays allergy testing outpatient surgery You pay a 10 copayment for office visits to your
primary care physician You pay a 10 copayment for office visits to a specialist allergy testing
and for each MRI or CT scan you receive You pay nothing for outpatient surgery laboratory tests
X rays prenatal care visits and well child visits through age 6 13

Home Health Care All necessary visits by nurses You pay a 10 copayment per visit 14
Mental Conditions You pay a 20 copayment for each individual therapy session and a 10 copayment for each group therapy session for Mental Conditions 20

Substance Abuse You pay a 10 copayment for each outpatient therapy session for the treatment of
Substance Abuse 21

Emergency Care Reasonable charges for services and supplies required because of a medical emergency You pay a 50 copayment to the hospital for each emergency room visit and any charges for services that are

not covered by this Plan You pay a 10 copayment to visit a primary care doctor or urgent care
center You pay a 10 copayment per visit to a specialist 18 19

Prescription Drugs Prescription drugs prescribed by a participating doctor and obtained at a participating pharmacy You and each family member pay the first 35 of prescription drug expense per year then for

each prescription unit or refill you pay a 5 copayment for a generic drug you pay a 15
copayment for a preferred brand drug on the formulary you pay a 25 copayment for a
non preferred and or a non formulary brand drug when written by a Plan doctor You pay two
copayments for up to a 90 days supply of maintenance drugs 21 23

Dental care Accidental injury benefit you pay a copayment for the services of a dentist or 50 if you are treated
in the emergency room for restorative services and supplies necessary to repair but not replace
sound natural teeth Preventive dental care comprehensive range of restorative orthodontic and
other services You pay nothing for most preventive and diagnostic services You pay moderate
copayments for other services and a 5 sterilization fee for each dental office visit 23 25

Vision care An annual routine eye examination refraction You pay a 10 copayment per visit 25

Out of pocket maximum Copayments are required for a few benefits however after your out of pocket expenses reach a
maximum of 650 per Self Only or 1,500 per Self and Family enrollment per calendar year
covered benefits will be provided at 100 This copayment maximum does not include copayments
for prescription drugs DME devices infertility services or dental benefits 5

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2000 Rate Information for
The George Washington University Health Plan

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 not a member of a special postal employment class refer to the category definitions
in The Guide to Federal Employees Health Benefits Plans for United States Postal Service Employees
RI 70 2 to determine which rate applies to you

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

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

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

Self Only E51 73.10 24.36 158.37 52.79 86.50 10.96 86.50 10.96
Self and E52 62.91 136.30 207.74 31.14 Family 175.97 381.27 201.02 37.86

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