Pages 1--28 from 6145pruD1R1_Texas

For changes
in benefits page 3
see

Serving Houston and San Antonio Texas Areas

Enrollment in this Plan is limited see page 4 for requirements
Enrollment code for Houston
UP1 Self only
UP2 Self and family

This plan has commendable accreditation
from the NCQA See the 2000 Guide
for more information on NCQA

Enrollment code for San Antonio
VX1 Self only
VX2 Self and family

This plan has commendable accreditation
from the NCQA See the 2000 Guide
for more information on NCQA

SPECIAL NOTICE Prudential HealthCare HMO Houston and Prudential HealthCare HMO San Antonio have been consolidated into a single benefit
package Please read your brochure carefully so that you are aware of all benefit changes

Visit the OPM website at http www opm gov insure
and
our Plan's website at http www aetnaushc com pruhealthcare

Authorized for distribution by the
UNITED STATES OFFICE OF PERSONNEL MANAGEMENT
RETIREMENT AND INSURANCE SERVICE
RI 73 048 1
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Prudential HealthCare HMO 2000
Table of Contents Page
Introduction .1
Plain language .1
How to use this brochure .2
Section 1 Health Maintenance Organizations .3
Section 2 How we change for 2000 .3
Section 3 How to get benefits .4
Section 4 What to do if we deny your claim or request for service .7
Section 5 Benefits .9
Section 6 General exclusions Things we don't cover .18
Section 7 Limitations Rules that affect your benefits .18
Section 8 FEHB FACTS .19
Inspector General Advisory Stop Healthcare Fraud .22
Summary of benefits Inside back cover
Premiums Back cover 2
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Prudential HealthCare HMO 2000
Introduction
Prudential Health Care Plan Inc Prudential HealthCare HMO
1425 Union Meeting Road P O Box 3013
Blue Bell PA 19422

This brochure describes the benefits you can receive from Prudential HealthCare Plan Inc hereafter referred to as Prudential HealthCare HMO under its contract CS 1774 with the Office of Personnel Management OPM as
authorized by the Federal Employees Health Benefits FEHB law This brochure is the official statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this brochure If you are enrolled
for Self and Family coverage each eligible family member is also entitled to these benefits
OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on page 3 Premiums are listed at the end of this brochure

Plain language
The President and Vice President are making the Government's communication more responsive accessible and understandable to the public by requiring agencies to use plain language Health plan representatives and Office of
Personnel Management staff have worked cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary technical terms you and other personal pronouns active voice and
short sentences
We refer to Prudential HealthCare HMO as this Plan throughout this brochure even though in other legal documents you will see a plan referred to as a carrier

These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year

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Prudential HealthCare HMO 2000
How to use this brochure

This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar
information to make comparisons easier
1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and how they work

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

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

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Prudential HealthCare HMO 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians hospitals and other providers that contract with us These providers coordinate your health care services The care you
receive includes preventative care such as routine office visits physical exams well baby care and immunizations as well as treatment for illness and injury

When you receive services from our providers you will not have to submit claim forms or pay bills However you must pay copayments and coinsurance listed in this brochure When you receive emergency services you may have to submit
claim forms
You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change plans because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider
will be available and or remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of treatment

Section 2 How we change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for all 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 information

You may review and obtain copies of your medical records on request If you want copies of your medical records ask your health care provider for them You may ask that a physician
amend a record that is not accurate not relevant or incomplete If the physician does not amend your record you may add a brief statement to it If they do not provide you your
records call us and we will assist you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This screening is for colorectal cancer

Changes to this We consolidated Prudential HealthCare HMO Houston and Prudential HealthCare Plan HMO San Antonio into a single benefits package known as Prudential HealthCare
HMO For enrollees who live in the San Antonio area the enrollment codes are VX1 Self only and VX2 Self and Family The enrollment codes for members who live or
work in the Houston service area are UP1 for Self Only and UP2 for Self and Family There are numerous benefit changes Please read your brochure very carefully

For San Antonio members VX1 and VX2 your share of the non postal premium increased by 15 for either Self Only or Self and Family In the Houston service area
your share of the non postal premium increased by 23.9 for Self Only UP1 and by 52.6 for Self and Family UP2

The office visit copay is 10.00 under the Medical and Surgical Benefits and Substance Abuse Benefits Previously the office visit copay was 5.00 See pages 9 and 15
Your prescription drug copays are based on the Plan's prescription drug formulary Your copay per prescription unit or refill for up to a 30 day supply will be 5.00 generic
formulary 10.00 name brand formulary or 20.00 non formulary We have eliminated the procedure for requesting non formulary drugs You may obtain up to a 90 day supply
of certain maintenance drugs with a single copay through the mail order pharmacy See page 15 of the Prescription Drug Benefits

The amount that you pay for the diagnosis and treatment of infertility has increased from 25 to 50 See page 10

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Prudential HealthCare HMO 2000
Section 2 How we change for 2000 continued
Changes to this The out of pocket maximum is 200 of the total premium per year Last year the Plan out of pocket maximum for Houston was 1000 for Self only and 2,500 for Self and

continued Family Previously the out of pocket maximum in San Antonio was 3,492 for Self only and 9,075 for Self and Family

You have up to 25 outpatient mental health care visits per calendar year You will pay 35 for each covered visit Previously members in San Antonio had 20 outpatient visits
See page 14
The hospital emergency room copay is 75.00 and the urgent care center copay is 10.00 Previously the hospital emergency room copay for San Antonio was 50.00 and
the urgent care copay was 5.00 Houston's urgent care copay was previously 5.00 See page 13 under the Emergency Benefits

Covered ambulance transport will be subject to a 25.00 copay Previously the copay was 50.00 for San Antonio members
You pay 25 of the charges for covered durable medical equipment prosthetic devices and orthopedic devices such as braces Previously San Antonio members paid 30 for
these items Houston previously covered prosthetic devices in full
Smoking cessation therapy that requires a prescription is covered under the Prescription Drug Benefits at the applicable generic name brand and non formulary copay Coverage
is limited to one 90 day course of treatment per lifetime administered by a Plan doctor

Section 3 How to get benefits
What is this Plan's To enroll with us you must live or work in our Houston service area UP or live or work in service area our San Antonio VX service area You must enroll in the code we have designated for
your area This is where our providers practice
Enrollment code UP Houston Service Area You must live or work in one of the following counties to enroll in this service code Our
Houston service area UP1 and UP2 includes the City of Houston and all of Fort Bend Galveston Harris Montgomery and Walker counties and portions of Austin Brazoira
Cambers Colorado Grimes Liberty Matagorda San Jacinto Waller Washington and Wharton counties inclusive of the following zip codes and communities

77001 77099 Houston 77201 77275 Houston Nassau Bay 77277 Houston 77279 77282 Houston 77284 Houston 77287 77293 Houston 77297 77304 Houston
Conroe 77306 Conroe 77327 Cleveland 77331 Coldspring 77336 77339 Huffman Tomball Humble 77345 77346 Humble 77355 77359 Magnolia Montgomery New
Caney New Waverly Oakhurst 77362 Pinehurst 77363 Plantersville 77365 Porter 77371 77373 Shephard Splendora Spring 77375 Tomball 77378 77389 Conroe
Spring Willis 77396 Humble 77401 Bellaire 77411 Howellville 77413 Barker 77417 Beasley 77418 Bellville 77420 Boling 77423 Brrokshire 77426 Chappell
Hill 77429 77430 Cypress Damon 77433 77435 Cypress Eagle Lake East Bernard 77441 Fukshear 77444 Guy 77445 Hempstead 77447 Hockley 77449 77450
Katy 77459 Missouri City 77461 Needville 77466 Pattison 77468 Pledger 77469 Richmond 77471 Rosenberg 77474 Sealy 77477 77479 Stafford Sugar Land
77481 Thompsons 77484 Walker 77485 Wallis 77486 West Columbia 77488 Wharton 77489 Missouri City 77491 77494 Katy 77501 77507 Pasadena 77510
77511 Santa Fe Alvin 77514 Anahuac 77515 Angleton 77517 77518 Santa Fe Baycliff 77520 75222 Baytown 77530 Channelview 77531 Clute 77532 Crosby
77534 Danbury 77535 Dayton 77536 Deer Park 77539 Dickenson 77541 Freeport 77545 77547 Fresno Friendswood Galena Park 77550 77551 Galveston
77554 Galveston 77560 Hankamer 77652 77653 Highlands Hitchcock 77564 Hull 77565 Kemah 77566 Lake Jackson 77568 Lamarque 77571 77574 La Porte League
City 77575 Liberty 77577 77578 Liverpool Manvel 77580 Mt Belview 77581 Pearland 77583 77584 Rosharon Pearland 77586 77587 Seabrook South Houston
77590 77592 Texas City 77597 Wallisville 77598 Webster 77560 Port Bolivar 77868 Navasota 77873 Richards 78933 Cat Spring

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Prudential HealthCare HMO 2000
Section 3 How to get benefits continued
What is this Plan's Enrollment code VX San Antonio Service Area service area You must live or work in one of the following counties or zip codes to enroll in this service

continued code Our San Antonio service area VX1 and VX2 includes the city of San Antonio and all of Bexar Comal Wilson and Guadaloupe counties and portions of Atascosa Bandera
Frio Karnes Kendall and Medina counties inclusive of the following zip codes and communities

78011 Charlotte 78026 Jourdanton 78050 Leming 78052 Lytle 78053 Mc Coy 78064 Pleasanton 78065 Poteet 78003 Bandera 78063 Pipe Creek 78002
Atascosa 78006 Boerne 78015 Fair Oaks Ra 78023 Helotes 78054 Macdona 78069 Somerset 78073 Von Ormy 78101 Adkins 78109 Converse 78112
Elmendorf 78148 78149 Universal City 78152 Saint Hedwig 78201 78265 San Antonio 78283 San Antonio 78285 78299 San Antonio 78080 Spring Branch
78130 78133 New Braunfels 78163 Wetmore 78623 Fischer 78005 Bigfoot 78057 Moore 78601 Pearsall 78108 Cibolo 78115 Geronimo 78123 Mc Queeney
78124 Marion 78154 Schertz 78155 78156 Seguin 78638 Kingsbury 78113 Falls City 78004 Bergheim 78027 Kendalia 78074 Waring 78009 Castroville 78016
Devine 78039 La Coste 78056 Mico 78059 Natalia 78066 Rio Medina 78861 Hondo 78886 Yancey 78114 Floresville 78121 La Vernia 78143 Pandora 78147
Poth 78160 Stockdale 78161 Sutherland
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 You must share the cost of some services This is called a copayment a set dollar amount pay for services i e 10 Please remember you must pay this amount when you receive services except for
laboratory tests and X rays
After you pay 200 of the annual premium for one family member or 200 of the annual premium this includes your premium and the government's share for two or more family
members you do not have to make any further payments for certain services provided or arranged by the Plan for the rest of the year This is called a catastrophic limit

Be sure to keep accurate records of your copayments and coinsurance since you are responsible for informing us when you reach the limits
Do I have to You normally won't have to submit claims to us unless you receive emergency services submit claims 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 Houston area UP1 and UP2 my health care Prudential HealthCare HMO is Houston's oldest health maintenance organization HMO
As a Plan member you may use the MacGregor Medical Association MMA physicians or Independent Provider Network IPN Primary Care Physicians listed in the provider
directories
If you select an MMA physician you have access to over 200 doctors at 19 full service health centers These centers are conveniently located throughout the Houston area You do
not have to designate a primary care doctor if you use MMA You may schedule an appointment with any MMA doctor by calling the centralized appointment desk at
713 741 2273
If you select an IPN primary care physician you have access to over 1,200 primary care physicians and over 2,500 specialists You may designate your IPN primary care doctor by
calling Prudential's Customer Service Department at 800 856 0764 You may schedule an appointment with your IPN doctor by calling that doctor directly You may transfer care
from IPN to MMA or from MMA to IPN by calling Customer Service for a change effective immediately

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Prudential HealthCare HMO 2000
Section 3 How to get benefits continued
Who provides We have 44 participating hospitals in the Houston area available to you as authorized by my health care your primary care doctor Please refer to the provider directories for specific doctor

continued hospital or pharmacy locations
San Antonio area VX1 and VX2 Prudential HealthCare HMO is a mixed model HMO that has provided medical benefits to

residents of San Antonio and surrounding communities for over 12 years We have over 500 primary care doctors and over 1,000 specialty care doctors in our physician network
Physicians are located throughout the service area and provide convenient quality medical care to our members Our hospital network consists of 26 area hospitals Prudential
HealthCare HMO members have access to pharmacies throughout the service area Please refer to the provider directory for specific doctor hospital and pharmacy locations

In Houston and San Antonio your Primary Care Physician will direct your care to a specialist hospital or ancillary provider that is contained within his or her chosen network
The Provider Directory accurately reflects the network of specialists hospitals and ancillary providers that your doctor may refer you to for care Please refer to your Provider
Directory for more specific information

What do I do if Call us at 1 800 856 0764 We will help you select a new one my primary care

physician leaves the Plan

What do I do if Talk to your Plan physician If you need to be hospitalized your primary care physician or I need to go into specialist will make the necessary hospital arrangements and supervise your care
the hospital
What do I do if First call our customer service department at 1 800 856 0764 If you are new to the FEHB I'm in the hospital Program we will arrange for you to receive care If you are currently in the FEHB Program

when I join this 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 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 receive a specialty care referral from your primary care physician before seeing any other doctor or obtaining
special services The only exceptions are when there is a medical emergency or when a primary care physician has designated another doctor to see his or her patients Also a
woman may self refer for covered services to her participating Obstetrician Gynecologist For all other services referral to a participating specialist is given at the primary care
physician's discretion If non Plan specialists or consultants are required the primary care physician will arrange appropriate referrals We will provide benefits for covered services
only when the services are medically necessary to prevent diagnose or treat your illness or condition

When you receive a referral from your primary care physician you must return to the primary care physician after the consultation All follow up care must be provided or
authorized by the primary care physician On referrals the primary care physician will give specific instructions to the consultant as to what services are authorized If the consultant
recommends additional services or visits you must first check with your primary care physician Do not go to the specialist unless the Plan has issued an authorization for the
referral in advance
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

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Prudential HealthCare HMO 2000
Section 3 How to get benefits continued
What do I do if Your primary care physician will decide what treatment you need If they decide to refer I am seeing a you to a specialist ask if you can see your current specialist If your current specialist does

specialist when not participate with us you must receive treatment from a specialist who does Generally I enroll we will not pay for you to see a specialist who does not participate with our Plan

What do I do if Call your primary care physician who will arrange for you to see another specialist You my specialist may receive services from your current specialist until we can make arrangements for you
leaves the Plan to see someone else
But what if I have a Please contact us if you believe your condition is chronic or disabling You may be able to serious illness and my continue seeing your provider for up to 90 days after we notify you that we are terminating

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

You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and you enroll in a new FEHB plan Contact the new plan and explain that you
have a serious or chronic condition or are in your second or third trimester Your new plan will pay for or provide your care for up to 90 days after you receive notice that your prior
plan is leaving the FEHB Program If you are in your second or third trimester your new plan will pay for the OB GYN care you receive from your current provider until the end of
your postpartum care
How do you Your Plan physician must get our approval before sending you to a hospital referring you to authorize medical a specialist or recommending follow up care Before giving approval we consider if the

services service is medically necessary and if it follows generally accepted medical practice
How do you decide We do not cover procedures services or supplies that are experimental or investigational if a service is In order to determine whether or not a procedure service or supply is experimental or

experimental or investigational we gather appropriate information for a decision that will be made by investigational medical professionals The information we collect may include medical records current
reviews of medical literature and scientific evidence results of current studies or clinical trials research protocols reports or opinions of authoritative medical bodies opinions of

independent outside experts and approvals granted by regulatory bodies Your provider may sometimes ask that you sign a form acknowledging that the procedure service or
supply is experimental or investigational This form and any related protocol may also be part of the information we consider After reviewing all pertinent information we make
our determination and notify you of our decision Please contact customer service at 800 856 0764 for more specific information

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

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Prudential HealthCare HMO 2000
Section 4 What to do if we deny your claim or request for service continued
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 refusal OPM will determine if we correctly applied the terms of our contract when we

a denial denied your claim or request for service
What if I have a Call us at 800 856 0764 and we will expedite our review serious or life

threatening condition and you haven't
responded to my request for service

What if you have If we expedite your review due to a serious medical condition and deny your claim we will denied my request inform OPM so that they can give your claim expedited treatment too Alternatively you
for care and my can call OPM's health benefits Contract Division 3 at 202 606 0755 between 8 a m and condition is serious 5 p m Serious or life threatening conditions are ones that may cause permanent loss of
bodily functions or death if they are not treated as soon as possible or life threatening

Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold time limits 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
What do I Your request must be complete or OPM will return it to you You must send the following send to OPM information

1 A statement about why you believe our decision is wrong based on specific benefit provisions in this brochure
2 Copies of documents that support your claim such as physicians letters operative reports bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim 4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to which claim

Who can make Those who have a legal right to file a disputed claim with OPM are the 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 OPM review to Office of Personnel Management Office of my disputed claim Insurance Programs Contract Division III P O Box 436 Washington D C 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 Federal law governs your lawsuit benefits and payment of benefits The Federal court will if 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
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Prudential HealthCare HMO 2000
Section 4 What to do if we deny your claim or request for service continued
Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects the Privacy Act from 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

Section 5 Medical and Surgical Benefits
What is covered We cover a comprehensive range of preventive diagnostic and treatment services by Plan doctors and other Plan providers This includes all necessary office visits You pay a 10
office visit copay but nothing for laboratory tests and X rays Within the Service Area house calls will be provided if in the judgment of the Plan doctor such care is necessary and
appropriate you pay a 10 copay for a doctor's house call nothing for home visits by nurses and health aides

The following services are included and are subject to the office visit copayment unless otherwise stated
Preventive care including well baby care and periodic check ups Sigmoidoscopy screening for colorectal cancer at age 50 and above every 5 years
Mammograms are covered as follows for women age 35 through age 39 one mammogram during these five years for women age 40 through 49 one mammogram
every one or two years for women age 50 through 64 one mammogram every year and for women age 65 and above one mammogram every two years In addition to routine
screening mammograms are covered when prescribed by the doctor as medically necessary to diagnose or treat your illness
Routine immunizations and boosters Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays Complete obstetrical maternity care for all covered females including prenatal
delivery and postnatal care by a Plan doctor The 10 copay is waived after the first prenatal office visit The mother at her option may remain in the hospital up to 48 hours
after a regular delivery and 96 hours after a cesarean delivery Inpatient stays will be extended if medically necessary If you terminate your enrollment in the Plan during
pregnancy benefits will not be provided after coverage under the Plan has ended Ordinary nursery care of the newborn child during the covered portion of the mother's
hospital confinement for maternity will be covered under either a Self Only or Self and Family enrollment Other care of an infant who requires definitive treatment will be
covered only if the infant is covered under a Self and Family enrollment Voluntary sterilization and family planning services and insertion of IUDs
Diagnosis and treatment of diseases of the eye Vision and hearing screenings up to age 18
Allergy testing and treatment including testing and treatment materials you pay 50 of charges We cover the cost of allergy serum in full Allergy injections performed in a
doctor's office are subject to the 10 office visit copay The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart lung kidney liver lung single or double pancreas and pancreaskidney transplants allogeneic donor bone marrow transplants autologous bone marrow
transplants autologous stem cell and peripheral stem cell support for the following conditions acute lymphocytic or non lymphocytic leukemia advanced Hodgkin's
lymphoma advanced non Hodgkin's lymphoma advanced neuroblastoma breast cancer multiple myeloma epithelial ovarian cancer and testicular mediastinal retroperitoneal
and ovarian germ cell tumors Transplants are covered when approved by the Plan's Medical Director Related medical and hospital expenses of the donor are covered when
the recipient is covered by this Plan

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Prudential HealthCare HMO 2000
Section 5 Medical and Surgical Benefits continued
What is covered Women who undergo mastectomies may at their option have this procedure performed continued on an inpatient basis and remain in the hospital for up to 48 hours after the procedure
Dialysis you pay nothing Chemotherapy radiation therapy and inhalation therapy you pay nothing
Surgical treatment of morbid obesity you pay nothing Orthopedic devices such as braces foot orthotics You pay 25 of charges
Prosthetic devices such as artificial limbs breast prostheses and surgical bras as well as their replacement and initial lenses or eyeglasses following cataract removal You pay 25
Durable Medical equipment such as hospital beds and wheelchairs You pay 25 of charges
Oxygen and rental of equipment for its administration Chiropractic services
Home health services of nurses and health aides including intravenous fluids and medications when prescribed by your Plan doctor who will periodically review the
program for continuing appropriateness and need You pay nothing 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 Diabetic supplies including needles glucose test tablets and test tape Benedicts solution
or equivalent acetone test tablets lancets and test strips You pay nothing
Limited Benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or
surgical procedures occurring within or adjacent to the oral cavity or sinuses including but not limited to treatment of fractures and excision of tumors and cysts Temporomandibular
joint disease is covered when determined to be of a medical rather than dental nature You pay nothing All other procedures involving the teeth or intra oral areas surrounding the
teeth are not covered including any dental care involved in treatment of temporomandibular joint TMJ pain dysfunction syndrome

Reconstructive surgery will be provided to correct a condition resulting from an abnormal congenital and or 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 You pay a 10 copayment per outpatient session Speech
therapy is limited to treatment of certain speech impairments of organic origin Occupational therapy is limited to services that assist the member to achieve and maintain
self care and improved functioning in other activities of daily living
Diagnosis and treatment of infertility is covered including prescription drugs and artificial insemination The covered artificial insemination procedures are intravaginal
insemination IVI intracervical insemination ICI and intrauterine insemination IUI You pay 50 of charges We do not cover the cost of donor sperm We do not cover the
harvesting storage and or manipulation of eggs and sperm Injectable fertility drugs are covered You pay 50 of charges Oral fertility drugs are covered under the Prescription
Drug Benefit All other assisted reproductive technology ART procedures such as in vitro fertilization and embryo transfer etc are not covered

Serious Mental Illness treatment is covered up to 45 days of inpatient care and 60 outpatient visits per calendar year Serious Mental Illness means the following psychiatric
illnesses as defined in the most recent edition of the American Psychiatric Association's Diagnostic and Statistical Manual of mental Disorders schizophrenia paranoid and other
psychotic disorders bipolar disorders hypomanic manic and mixed major depression disorders bipolar and depressive schizoaffective disorder bipolar or depressive pervasive
development disorders obsessive compulsive disorders and depression in childhood and adolescence You pay nothing for inpatient care and a 10 copay for each covered outpatient
visit up to 60 visits all charges thereafter Mental illnesses that do not meet the definition of serious mental illness are covered under Mental Conditions Substance Abuse benefits

Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is provided at a Plan facility You pay nothing
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Prudential HealthCare HMO 2000
Section 5 Medical and Surgical Benefits continued
What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance attending school or camp or travel
Reversal of voluntary surgically induced sterility Surgery primarily for cosmetic purposes
Transplants not listed as covered Any eye surgery solely for the purpose of correcting refractive defects of the eye such as
nearsightedness myopia farsightedness hyperopia and astigmatism Hearing aids including examinations for the fitting of them the cost of cochlear implants
Homemaker services Blood and blood derivatives replaced by or for the patient

Section 5 Hospital Extended Care Benefits
What is covered
Hospital care We provide a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan doctor You pay nothing All necessary services are
covered including
Semiprivate room accommodations when a Plan doctor determines it is medically necessary the doctor may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units
Extended care We provide a comprehensive range of benefits for up to 100 days per condition for all such confinements which are due to the same or related causes and which are separated by less
than three months Coverage is provided when full time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as determined by a
Plan doctor and approved by the Plan You pay nothing All necessary services are covered including

Bed board and general nursing care Drugs biologicals supplies and equipment ordinarily provided or arranged by the
skilled nursing facility when prescribed by a Plan doctor
Hospice Care Supportive and palliative care for a terminally ill member is covered in the home or hospice facility Services include inpatient and outpatient hospice care and are provided under the
direction of a Plan doctor who certifies that the patient is in the terminal stages of illness with a life expectancy of approximately six months or less Each person is entitled to a
maximum benefit of 7,400 per period of care Up to 200 in counseling services may be provided to the family unit of the terminally ill patient

Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor You pay a 25 copay per occurrence
Limited benefits
Inpatient dental We cover hospitalization for certain dental procedures when a Plan doctor determines there procedures is a need for hospitalization for reasons totally unrelated to the dental procedure Although
we will cover the hospitalization we do not cover the cost of the professional dental services Conditions for which we cover hospitalization would include hemophilia and
heart disease However 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

Serious Mental Illness We provide a comprehensive range of benefits for inpatient care for up to 45 days when you are hospitalized for serious mental illness under the care of a Plan doctor You pay nothing
Each full day of treatment in a Psychiatric Day Treatment Facility Residential Treatment Center for Children and Adolescents or Crisis Stabilization Unit will be considered a half of
one day of treatment during a Hospital Inpatient stay

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Section 5 Hospital Extended Care Benefits continued
Serious Mental Illness Serious Mental Illness means the following psychiatric illnesses as defined in the most continued recent edition of the American Psychiatric Association's Diagnostic and Statistical Manual
of Mental Disorders schizophrenia paranoid and other psychotic disorders bipolar disorders hypomanic manic and mixed major depressive disorders bipolar and
depressive schizoaffective disorders bipolar or depressive pervasive developmental disorders obsessive compulsive disorders and depression in childhood and adolescence
Mental illnesses that do not meet the definition of serious mental illness are covered under Mental Conditions Substance Abuse Benefits

What is not covered Personal comfort items such as telephone and television Custodial care rest cures domiciliary or convalescent care
Blood and blood derivatives replaced by or for the patient

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Prudential HealthCare HMO 2000
Section 5 Emergency Benefits
What is a A medical emergency is the sudden and unexpected onset of a condition or an injury that medical emergency requires immediate medical or surgical care Some problems are emergencies because if
not treated promptly they might become more serious examples include deep cuts and broken bones Others are emergencies because they are potentially life threatening such as
heart attacks strokes poisonings gunshot wounds or sudden inability to breathe There are many other acute conditions that we may determine are medical emergencies what they all
have in common is the need for quick action
Emergencies 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 us You or
a family member must notify us within 48 hours unless it was not reasonable possible to do so It is your responsibility to ensure that we have been timely notified

If you need to be hospitalized we must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to notify the Plan
within that time If you are hospitalized in non Plan facilities and Plan doctors believe care can be better provided in a Plan hospital you will be transferred when medically feasible
with any ambulance charges covered in full
Benefits are available for care from non Plan providers in a medical emergency only if delay in reaching a Plan provider would result in death disability or significant jeopardy to
your condition
To be covered by this plan any follow up care recommended by non plan providers must be approved by the plan or provided by plan providers

We pay Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 75 per hospital emergency room visit or 10 per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a
hospital we waive the emergency care copay
Emergencies outside Benefits are available for any medically necessary health service that is immediately the service area required because of injury or unforeseen illness

If you need to be hospitalized we must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to notify us within that
time If a Plan doctor believes care can be better provided in a Plan hospital you will be transferred when medically feasible with any ambulance charges covered in full

To be covered by this plan any follow up care recommended by non plan providers must be approved by the plan or provided by plan providers
We pay Reasonable charges for emergency care services to the extent the services would have been covered if received from Plan providers
You pay 75 per hospital emergency room visit or 10 per urgent care center visit for emergency services that are covered benefits of this Plan Urgent care services rendered outside the
service area must be coordinated through the Prudential National Service Hotline for the 10 copay to apply If the emergency results in admission to a hospital we waive the
emergency care copay
What is covered Emergency care at a doctor's office or an urgent care center minor emergency center Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service approved by the Plan
What is not covered Elective care or non emergency care Emergency care provided outside the service area if the need for care could have been
foreseen before leaving the service area
Filing claims for With your authorization we 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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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Section 5 Emergency Benefits continued
receipts to us along with an explanation of the services and the identification information from your ID card
We will send payment to you or the provider if you did not pay the bill unless we deny benefits for the claim If we deny benefits we will send you a written notice of our
decision including the reasons for the denial and the provisions of the contract on which we based our decision If you disagree with us you may ask us to reconsider our decision in
accordance with the disputed claims procedure described on page 7
Portability If you are away from home and require medical care other than routine physicals immunizations and non emergency maternity care you can access a network facility in the
area you are visiting You will receive this care at the maximum benefit level as if you were at home free of bills and claim forms

To obtain these benefits you must do one of two things Contact your primary care doctor or medical group to obtain permission for out of area
care In life threatening emergencies we recommend that you seek appropriate treatment immediately However you or a member of your family must notify your primary care
doctor within 48 hours concerning the emergency care you received Contact the Prudential HealthCare office in the city you are visiting or the Prudential
National Hotline 1 800 526 2963 to obtain a referral to a local participating physician This toll free number is also located on the back of your member ID card and is
answered 24 hours a day
Your home plan is responsible for reimbursing the providers in the out of area Prudential HealthCare HMO plan You should not be asked to make payments except applicable
copays or file a claim form unless you receive authorized treatment from a non Prudential HealthCare provider

Section 5 Mental Conditions Substance Abuse Benefits
In the Houston area members must contact University Behavioral Health at 713 666 3794 for access to mental health substance abuse services

In the San Antonio area members must contact Alamo Mental Health at 210 614 8400 for access to mental health substance abuse

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 Serious Mental Illness treatment is covered under the Medical Surgical Benefits or
Hospital Extended Care Benefits Serious Mental Illness means the following psychiatric illnesses as defined in the most recent edition of the American Psychiatric Association's
Diagnostic and Statistical Manual of mental Disorders schizophrenia paranoid and other psychotic disorders bipolar disorders hypomanic manic and mixed major depression
disorders bipolar and depressive schizoaffective disorder bipolar or depressive pervasive development disorders obsessive compulsive disorders and depression in
childhood and adolescence
Outpatient care Up to 25 visits for individual counseling with Plan doctors consultants or other psychiatric personnel each calendar year you pay a 35 copay for each covered visit all charges
thereafter
Inpatient care Up to 30 days of hospitalization each calendar year you pay nothing for the first 30 days all charges thereafter

Intermediate care Intermediate care for mental health accumulates towards the 30 day inpatient care hospital
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 14 16
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Prudential HealthCare HMO 2000
Section 5 Mental Conditions Substance Abuse Benefits continued
Intermediate care maximum Each full day of treatment in a Psychiatric Day Treatment Facility Residential continued Treatment Center for Children and Adolescents or Crisis Stabilization Unit two days will
be considered a half of one day of treatment during a Hospital Inpatient Stay
What is not covered Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to significant improvement through relatively short term treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless determined by a Plan doctor to be necessary and appropriate
Psychological testing when not medically necessary to determine the appropriate treatment of a short term psychiatric condition

Substance Abuse
What is covered We provide 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 All necessary outpatient visits to Plan providers for treatment are covered you pay a 10 copay for each covered visit
Inpatient Care Hospitalization necessary for the diagnosis and treatment of Substance Abuse you pay nothing
What is not covered Treatment that is not authorized by a Plan doctor

Section 5 Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will be dispensed for up to a 30 day supply or one commercially prepared unit i e one
inhaler one vial ophthalmic medication or insulin You pay a 5 copay per prescription unit or refill for generic formulary drugs or a 10 copay per prescription unit or refill for name
brand formulary drugs or a 20 copay per prescription unit or refill for non formulary drugs However in no event will the copay exceed the cost of the prescription

Maintenance drugs are used for the treatment of the following chronic medical conditions chronic obstructive pulmonary disease clotting drugs congestive heart failure coronary
artery disease angina diabetes glaucoma hypertension thyroid disease and seizure disorders We may also include other conditions

Up to a 90 day supply of maintenance drugs and oral contraceptive drugs prescribed by a Plan doctor may be obtained from our mail order pharmacy You pay a 5 copay per
prescription unit or refill for generic formulary drugs or a 10 copay per prescription unit or refill for name brand formulary drugs or a 20 copay per prescription unit or refill for
non formulary drugs
Drugs are prescribed by Plan doctors and dispensed in accordance with our drug formulary
Non formulary drugs will be covered when prescribed by a Plan doctor subject to the 20 non formulary copay If you would like to obtain additional information about our
formulary please call Prudential HealthCare customer service at 1 800 856 0764 or visit our website at www aetnaushc com pruhealthcare

Formulary Our Prudential Health Care Drug Formulary was developed and is maintained by the development Prudential HealthCare National Pharmacy and Therapeutics committee P T with the
understanding that a well constructed formulary enhances quality of care The P T committee evaluates the clinical use of drugs and develops policies and procedures for
developing new drug therapies and managing the formulary The P T committee is also responsible for conducting therapeutic class reviews and analyzing new drugs as they enter
the market The formulary reflects our medical and pharmaceutical experience in formulary management and rigorous reviews of individual clinical studies

The following are examples of what a copay applies to
Up to a 30 day supply of tablets capsules and liquids to be taken orally or as indicated for use by the Food and Drug Administration FDA For example Diflucan VC is FDA

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Section 5 Prescription Drug Benefits continued
Examples continued indicated as a single dose treatment and a copay will be charged for each tablet The treatment usage for many antibiotics will be for a 10 day supply or less for which one
copay would apply a manufacturer's standard 10 milliliter vial of insulin
insulin syringes a copay applies to each package of 100 a package of no more than 15 milliliters of any optic or opthalmic product
a manufacturer's smallest standard package of nasal or oral inhaler a manufacturer's smallest standard package of nebulizer solution
1 manufacturer's smallest standard package of liquid or solid rectal or vaginal medication
1 manufacturer's smallest standard package containing no more than 60 milliliters of topical solutions or lotions
1 manufacturer's smallest standard package containing no more than 60 grams of topical ointments or creams
Up to a 30 day supply of patches a copay applies to each manufacturer's standard package 1 package of oral contraceptives
1 diaphragm unit
Covered medications Drugs for which a prescription is required by law and accessories include Oral contraceptives up to a 90 day supply per refill of maintenance and oral
contraceptive drugs may be obtained with a copay applied to each 30 day supply filled at the local participating pharmacy
Contraceptive devices including diaphragms Insulin with a copay charge applied to each vial
Disposable needles and syringes included with the insulin prescription Oral drugs prescribed for the treatment of infertility

Diabetic supplies except insulin disposable needles and syringes needed for injecting medication other than insulin intravenous fluids and medications for home use implantable
drugs such as Norplant and injectable drugs such as Depo Provera and some fertility drugs are covered under the Medical and Surgical Benefits

Limited benefits Sexual dysfunction drugs have dispensing limitations For complete details please call Prudential HealthCare customer service at 800 856 0764
Smoking cessation aids Smoking cessation therapy that requires a prescription is covered subject to the following
limitations You pay a 5 copay for each generic formulary supply and a 10 copay for each name brand formulary supply and a 20 copay for each non formulary supply

What is not covered Drugs available without prescription or for which there is a nonprescription equivalent available
Drugs obtained at a non Plan pharmacy except out of area emergencies Vitamins and nutritional substances which can be obtained without a prescription
Medical supplies such as dressing and antiseptics Drugs for cosmetic purposes
Drugs to enhance athletic performance

Section 5 Other Benefits
Dental care
Accidental injury Restorative services and supplies necessary to promptly repair or replace sound natural benefit teeth are covered Dental implants are not covered The need for these services must result
from an accidental injury You pay nothing
What is not covered Other dental services not shown as covered
Vision care
What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye annual eye refractions which include the written lens prescription for
eyeglasses glaucoma testing dilation from Plan providers You pay a 10 copay per visit
What is not covered Eye exercises Eyeglasses and frames
Contact lenses or the fitting of contact lenses 16

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 18
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Prudential HealthCare HMO 2000
Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB program but are made available to all enrollees and family members who are members of the Plan The cost of the benefits described on this
page is not included in the FEHB premium any charges for these services do no count toward any FEHB deductibles or outof pocket maximums These benefits are not subject to the FEHB disputed claims procedures

Along with the medical benefits described elsewhere Prudential HealthCare HMO gives you access to additional programs that can enhance your quality of life

Dental Program
The Dental Program is a comprehensive dental plan with no claims form or deductibles It is not insurance it's a discount dental program with more than 10,000 participating dentists across the country These dentists have agreed to provide
services to program participants at reduced rates including periodic exams cleanings even orthodontia care
For as little as 5.00 per month 6.00 for families you will have access to a full range of dental services at a substantial discount You can enroll by submitting a completed application and a full year's premium 60.00 for an individual and 72.00
for a family by the open season deadline Please note this is not a payroll deducted plan Applications and more details about the Dental Program are included in your Prudential HealthCare open enrollment packet You may contact Benefit
Network Systems at 1 800 391 9721 for more information

Vision Program
As a Prudential HealthCare HMO member you can obtain discounts on eyeglasses and frames at designated locations

Medicare Prepaid Plan Enrollment
This Plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare As indicated on page 18 annuitants and former spouses with the FEHBP coverage and Medicare Part B may elect to drop their FEHB coverage and
enroll in a Medicare prepaid plan when one is available in their area They may then later reenroll in the FEHB Program Most Federal annuitants have Medicare Part A Those without Medicare Part A may join this Medicare prepaid plan but will
probably have to pay for hospital coverage in addition to the Part B premium Before you join the plan ask whether the plan covers hospital benefits and if so what you will have to pay Contact your retirement system for information on dropping
your FEHB enrollment and changing to a Medicare prepaid plan Contact us at 1 800 772 3496 in the Houston area or 1 800 781 7952 in the San Antonio area for information on the Medicare prepaid plan and the cost of that enrollment

If you are Medicare eligible and are interested in enrolling in a Medicare HMO sponsored by this Plan without dropping your enrollment in this Plan's FEHB plan call 1 800 772 3496 in the Houston area or 1 800 781 7952 in the San Antonio area for
information on benefits available under the Medicare HMO

Benefits on this page are not part of the FEHB contract
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Prudential HealthCare HMO 2000
Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition

We do not cover Services drugs or supplies that are not medically necessary the following Services not required according to accepted standards of medical dental or psychiatric
practice Care by non Plan providers except for authorized referrals or emergencies see
Emergency Benefits Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is
the result of an act of rape or incest Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan

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 see page 17
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 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 beyond our control to provide them In that case we will make all reasonable efforts to provide you with
necessary care

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Prudential HealthCare HMO 2000
Section 7 Limitations Rules that affect your benefits continued
When others are When you receive money to compensate you for medical or hospital care for injuries or responsible for injuries illness 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

Section 8 FEHB FACTS
You have a right to information about your HMO
OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right to information about your health plan its networks providers and facilities You can 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 800 856 0764 or write to Prudential Healthcare 1425 Union Meeting Road P O Box 3013 Blue Bell PA 19422 You may also contact us by fax at 215 775 5870 or visit our website at
www aetnaushc com pruhealthcare
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 The benefits in this brochure are effective on January 1 If you are new to this plan your benefits and coverage and premiums begin on the first day of your first pay period that starts on or after
premiums 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

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Prudential HealthCare HMO 2000
Section 8 FEHB FACTS continued
What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and coverage are your unmarried dependent children under age 22 including any foster or step children your

available for my employing or retirement office authorizes coverage for Under certain circumstances you family and me may also get coverage for a disabled child 22 years of age or older who is incapable of selfsupport

If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry give birth or add a child to your family You may change your enrollment 31 days
before to 60 days after you give birth or add the child to your family The benefits and premiums for your Self and Family enrollment begin on the first day of the pay period in
which the child is born or becomes an eligible family member
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits nor will we Please tell us immediately when you add or
remove family members from your coverage for any reason including divorce
If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled in another FEHB plan

Are my medical We will keep your medical and claims information confidential Only the following will and claims records have access to it
confidential OPM this Plan and subcontractors when they administer this contract
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions

OPM and the General Accounting Office when conducting audits 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 We will send you an Identification ID card Use your copy of the Health Benefits Election cards Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card
You can also use an Employee Express confirmation letter

What if I paid a Your old plan's deductible continues until our coverage begins deductible under

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

When you lose benefits
What happens if You will receive an additional 31 days of coverage for no additional premium when my enrollment in Your enrollment ends unless you cancel your enrollment or

this Plan ends You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage

What is former If you are divorced from a Federal employee or annuitant you may not continue to get spouse coverage benefits 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
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Prudential HealthCare HMO 2000
Section 8 FEHB FACTS continued
What is TCC Key points about TCC continued
You can pick a new plan If you leave Federal service you can receive TCC for up to 18 months after you
separate If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends If you or your employing office delay processing your request you still have to pay
premiums from the 32nd day after your regular coverage ends even if several months have passed
You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll If you leave Federal service your employing office will notify you of your right to enroll in TCC 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 Certificate of Group Coverage that indicates how long you have been enrolled with us You can use this

Health Plan Coverage certificate when 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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Prudential HealthCare HMO 2000
Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for services you did not receive billed you twice for the same service or misrepresented any information do the

following Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 800 856 0764 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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Prudential HealthCare HMO 2000
Notes

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Prudential HealthCare HMO 2000
Notes

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Prudential HealthCare HMO 2000
Summary of Benefits for Prudential HealthCare HMO 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set forth in the brochure This chart merely summarizes certain important expenses covered by the Plan If you
wish to enroll or change your enrollment in this Plan be sure to indicate the correct enrollment code on your enrollment form codes appear on the cover of this brochure ALL SERVICES COVERED UNDER THIS PLAN WITH THE
EXCEPTION OF EMERGENCY CARE ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN DOCTORS

Benefits Plan pays provides Page
Inpatient care Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes in hospital doctor care room and board general
nursing care private room and private nursing care if medically necessary diagnostic tests drugs and medical supplies use of operating
room intensive care and complete maternity care You pay nothing 11
Extended care All necessary services up to 100 days per condition You pay nothing 11
Serious Mental Diagnosis and treatment of Serious Mental Illnesses is covered up to Illnesses 45 days of inpatient care per year You pay nothing 11

Other Mental Diagnosis and treatment of acute psychiatric conditions for up to conditions 30 days of inpatient care per year You pay nothing 14
Substance Abuse Hospitalization necessary for diagnosis and treatment You pay nothing 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
10 copay per office visit 10 per house call by a doctor 9
Home health care All necessary visits by nurses and health aides You pay nothing 10
Serious Mental Diagnosis and treatment of Serious Mental Illness is covered up to illness 60 visits You pay a 10 copay per visit 10

Other Mental Up to 25 outpatient visits per year You pay a 35 copay per visit 14 conditions
Substance abuse All necessary outpatient visits are covered You pay a 10 copay per visit 15
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 75 copay to the hospital for each
emergency room visit or a 10 urgent care provider office visit and any charges for services that are not covered by this Plan 13

Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5 copay per prescription unit or refill for a generic
formulary drug and a 10 copay for a brand name formulary drug and a 20 copay for a non formulary drug 15

Dental care Accidental injury benefit you pay nothing Preventive dental care no current benefit 16
Vision care One refraction annually You pay a 10 copay per visit 16
Out of pocket maximum Copayments are required for a few benefits however after your out of pocket expenses reach a maximum of 200 of annual premiums
for Self Only 200 of annual premiums per Self and Family enrollment per calendar year including your premium and the Government's share
covered benefits will be provided at 100 This copay maximum does not include charges for vision care or prescription drugs 5

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2000 Rate Information for
Prudential HealthCare HMO

Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the FEHB
Guide for that category or contact the agency that maintains your health benefits enrollment

Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates referred
to as Category A rates and Category B rates will apply for certain career employees If you are a career postal
employee but not a member of a special postal employment class refer to the category definitions in The Guide to
Federal Employees Health Benefits Plans for United States Postal Service Employees RI 70 2 to determine which
rate applies to you

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

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

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

San Antonio Area
Self Only VX1 64.78 21.59 140.36 46.78 76.65 9.72 76.65 9.72
Self and Family VX2 168.29 56.09 364.62 121.54 199.14 25.24 199.14 25.24

Houston Area
Self Only UP1 65.61 21.87 142.16 47.38 77.64 9.84 77.64 9.84

Self and Family UP2 175.97 78.26 381.27 169.56 207.74 46.49 201.02 53.21

RRD 8104860
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