action type is Thread Had trouble resolving dest near word

action type is Thread Had trouble resolving dest near word action type is Thread Had trouble resolving dest near word

action type is Thread Had trouble resolving dest near word action type is Thread Pages 1--36 from gafedhan.p65 Document Body Page Navigation Panel

Pages 1--36 from gafedhan.p65

Page 1 2
OmniCare Health Plan 2000
A Health Maintenance Organization

Serving Southeast Michigan For see
Enrollment in this Plan is limited see page 5 for requirements
changesin
benefits page 4

Enrollment Code KA1 Self only
KA2 Self and family

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

Visit the OPM website at http wwwopmgovinsure and
our website at httpwwwochpcom

Authorized for distribution by the
UNITED STATES OFFICE OF PERSONNEL MANAGEMENT
RETIREMENT AND INSURANCE SERVICE

RI 73062 1
1 Page 2 3

OmniCare Health Plan 2000
Table of Contents Page

IntroductionIntroduction 1
PlainPlain Language 1
HowHow To Use This Brochure 2
SectionSection 1 Health Maintenance Organizations 3
SectionSection 2 How We Change For 2000 4
SectionSection 3 How To Get Benefits 5 7
SectionSection 4 What To Do If We Deny Your Claim Or Request For Service 8 9
SectionSection 5 Benefits 10 21
SectionSection 6 General Exclusions Things We Dont Cover 22
SectionSection 7 Limitations Rules That Affect Your Benefits 23 24
SectionSection 8 FEHB FACTS 25 28
InspectorInspector General Advisory Stop Healthcare Fraud 29
SummarySummary Of Benefits Inside Back Cover
PremiumsPremiums Back Cover 2
2 Page 3 4
OmniCare Health Plan 2000
Introduction

OmniCare Health Plan 1155 Brewery Park Blvd Detroit Michigan 48207

This brochure describes the benefits you can receive from OmniCare Health Plan under its contract CS1871 with the
O ffice 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 4 Premiums are listed at the end of this brochure

Plain Language
The President and Vice President are making the Governments communication more responsive accessible and under
standable 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 OmniCare Health Plan 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 rewritten the Benefits section of this brochure You will find new benefits language next year

1 3
3 Page 4 5
OmniCare 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 Plans 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
6 General exclusions Things we dont 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

2 4
4 Page 5 6
OmniCare 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 preventative care such as routine office visits physical exams wellbaby 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 plans 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 andor remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of treatment

3 5
5 Page 6 7
OmniCare Health Plan 2000
Section 2 How We Change For 2000
Programwide To keep your premium as low as possible OPM has set a minimum copay of 10 for all primary changes care office visits

This year you have a right to more information about this Plan care management our net works 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 OBGYN until the end of your postpartum care You have similar rights if this Plan leaves
the FEHB program See Section 3 How To Get Benefits for more information
You may review and obtain copies of your medical records on request If you want copies of your medical records ask your health care provider for them You may ask that a physician
amend a record that is not accurate not relevant or incomplete If the physician does not amend your record you may add a brief statement to it If they do not provide you your
records call us and we will assist you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This screening is for colorectal cancer

Changes to this Your share of the NonPostal premium will decrease by 4 for Self Only or 4 for Self and Plan Family
Female members may see their Plan gynecologist for routine womens health related services without requiring a referral from a PCP
The office visit copay increased to 10 from nothing under Medical and Surgical Benefits Shortterm rehabilitation therapy Diagnosis and treatment of infertility Cardiac rehabilitation
Dental Benefits and Vision Care See pages 10 11 17 and 21

4 6
6 Page 7 8
OmniCare Health Plan 2000
Section 3 How To Get Benefits

What is this To enroll with us you must live or work in our service area This is where our providers
Plans service practice Our service area covers the Michigan counties of Wayne Oakland Monroe area Macomb and Washtenaw

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
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 feeforservice plan or an HMOthat 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 either a copayment a set dollar pay for amount or coinsurance a set percentage of charges Please remember you must pay this
services amount when you receive services Your outofpocket expenses for benefits covered under this Plan are limited to the stated copayments required for a few benefits

Do I have You normally wont have to submit claims to us unless you receive emergency services from to submit a provider who doesnt contract with us If you file a claim please send us all of the
claims 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 OmniCare Health Plan is a Mixed Model Prepayment Plan This means you have the options of my health care selecting your primary care doctor from the group practice list or you may select your primary
care doctor from the list of individual practice doctors There are approximately 621 primary care doctors to choose from and over 1315 specialists who are available for referral care

All family members do not have to use the same primary care doctor Each family member may have their own specific primary care doctor
It is through the primary care doctor that all other health services particularly those of specialists are obtained It is the responsibility of your primary care doctor to obtain any
necessary authorizations from the Plan before referring you to a specialist or making arrangements for hospitalization Services of other providers are covered only when you
have been referred by your primary care doctor The only exception is that women may see her participating provider of obstetric and gynecological of record directly with no need to be
referred by her primary care doctor
The Plans provider directory lists primary care doctors with their locations and phone
numbers Directories are updated on a regular basis and are available at the time of

enrollment or upon request by calling the Customer Service Department at 18004776664

Important note When you enroll in this Plan services except for emergency benefits are provided through the Plans delivery system the continued availability andor participation of
any one doctor hospital or other provider cannot be guaranteed

5 7
7 Page 8 9
OmniCare Health Plan 2000
Section 3 How To Get Benefits continued

What do I do if my Call us We will help you select a new one Please call Customer Service at 18004776664 primary care
physician leaves the Plan

What do I do if I Talk to your Plan physician If you need to be hospitalized your primary care physician or
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 18004776664 If you are new to the FEHB
Im in the hospital Program we will arrange for you to receive care If you are currently in the FEHB Program and
when I join this are switching to us your former plan will pay for the hospital stay until
Plan
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 Except in a medical
specialty care emergency or when a primary care doctor has designated another doctor to see his or her
patient you must receive a referral from your primary care doctor before seeing any other
doctor or obtaining special services Referral to a participating specialist is given at the
primary care doctors discretion if nonPlan specialists or consultants are required the primary
care doctor will arrange appropriate referrals If you feel you are not receiving proper referrals
to specialists please contact Customer Service at 18004776664

When you receive a referral from your primary care doctor you must return to the primary care
doctor after the consultation unless your doctor authorized additional visits All followup
care must be provided our authorized by the primary care doctor Do not go to the specialist
for a second visit unless your primary care doctor has arranged for and 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 with you and your health
plan that allows you to see your specialist for an adequate number of visits without additional
referrals

What do I do if Your primary care physician will decide what treatment you need If they decide to refer you to
I am seeing a a specialist ask if you can see your current specialist If your current specialist does not specialist when participate with us you must receive treatment from a specialist who does Generally we will

I enroll 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 may my specialist leaves receive services from your current specialist until we can make arrangements for you to see

the Plan someone else on a referral basis
6 8
8 Page 9 10
OmniCare Health Plan 2000
Section 3 How To Get Benefits continued

But what if I Please contact us if you believe your condition is chronic or disabling You may be able to have a serious continue seeing your provider for up to 90 days after we notify you that we are terminating
illness and my our contract with the provider unless the termination is for cause If you are in the second provider leaves or third trimester of pregnancy you may continue to see your OBGYN until the end
of your the Plan or this postpartum care

Plan 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 OBGYN care you receive from your current provider until the end of your postpartum
care

How do you Your physician must get our approval before sending you to a hospital referring you to a authorize medical specialist or recommending followup care Before giving approval we consider if the service
services is medically necessary and if it follows generally accepted medical practice The plan will provide benefits for covered services only when the services are medically necessary to
prevent diagnose or treat your illness or condition
For mental health services each member must select a Mental Health Center If you do not select a Mental Health Center one will be chosen for you Please contact Customer Service at

18004776664 for Mental Health Center locations
How do you The Plan bases its determination of whether or not a treatment service or supply is experimen
decide if a service tal or investigational in nature if there is no consensus in the medical community as to the
is experimental or safety or effectiveness of the technology or the treatment as applied to the patients medical
investigational problem or there is insufficient evidence to determine its appropriateness in a given situation
or the technology is undergoing clinical trials or is largely confined to research protocols or
the physician or facility rendering the treatment classifies the treatment as experimental or
investigational for purposes of obtaining an informed consent

Experimental and investigational drugs are not approved by the FDA and are not available to
the general public These drugs may be available if prior approval is received from OmniCare

7 9
9 Page 10 11
OmniCare Health Plan 2000
Section 4 What To Do If We Deny Your Claim Or Request For Service
If we deny services or wont pay your claim you may ask us to reconsider our decision Your request must

1 Be in writing 2 Refer to specific brochure wording explaining why you believe our decision is wrong
and 3 Be made within six months from the date of our initial denial or refusal We may
extend this time limit if you show that you were unable to make a timely request due to reasons beyond your control

We have 30 days from the date we receive your reconsideration request to 1 Maintain our denial in writing
2 Pay the claim 3 Arrange for a health care provider to give you the service or
4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30 days after we receive the additional information If we do
not receive the requested information within 60 days we will make our decision based on the
information we already have

When may I ask 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 Call us at 18004776664 and we will expedite our review
a serious or life
threatening
condition and you
havent responded
to my request for
service

What if you have If we expedite your review due to serious medical condition and deny your claim we will inform
denied my request OPM so that they can give your claim expedited treatment too Alternatively you may call
for care and my OPMs health benefits Contract Division III at 202 6060755 between 8 am and 5 pm Serious
condition is serious or lifethreatening conditions are ones that may cause permanent loss of bodily functions or
or life threatening death if they are not treated as soon as possible

Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold
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

8 10
10 Page 11 12
OmniCare Health Plan 2000
Section 4 What To Do If We Deny Your Claim Or Request For Service cont What do I send Your request must be complete or OPM will return it to you You must send the

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

If you want OPM to review different claims you must clearly identify which docu
ments 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 persons representative They must send a copy of the persons 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 OPMs decision is final There are no other administrative appeals If OPM agrees with our
upholds the Plans decision your only recourse is to sue
denial
If you decide to sue you must file the suit against OPM in Federal court by December 31 of
the third year after the year in which you received the disputed services or supplies

What laws apply if Federal law governs your lawsuit benefits and payment of benefits The Federal court will
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 treat
ment services supplies or drugs covered by us until you have completed the OPM review
procedure described above

Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects from the 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
9 11
11 Page 12 13
OmniCare Health Plan 2000
Section 5 BENEFITS Medical and Surgical Benefits

What is covered A comprehensive range of preventive diagnostic and treatment services are provided by Plan doctors and other Plan providers You pay a 10 office visit copay but no additional copay for
laboratory tests and Xrays Within the service area house calls will be provided if in the judgment of the Plan doctor such care is necessary and appropriate you pay nothing for a
doctors house calls or for home visits by nurses and health aides
The following services are included and are subject to the office visit copay unless stated otherwise
i Preventive care including wellbaby care and periodic checkup
i 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 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 i Routine immunizations and boosters
i Consultations by specialists
i Diagnostic procedures such as laboratory tests and Xrays
i Complete obstetrical maternity care for all covered females including prenatal delivery and

postnatal care by a Plan doctor Office visit copays are waived for maternity care 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 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 mothers hospital confinement for maternity will be covered under
either a Self Only or Self and Family enrollment other care of an infant who requires defini tive treatment will be covered only if the infant is covered under a Self and Family enrollment
i Voluntary sterilization and family planning services
i Diagnosis and treatment of diseases of the eye
i Allergy testing and treatment including testing and treatment materials such as allergy

serum
i The insertion of internal prosthetic devices such as pacemakers and artificial joints
i Cornea heart heartlung kidney liver lung single or double and pancreas transplants

autologous bone marrow transplants autologous stem cell and peripheral stem cell support allogeneic donor bone marrow transplants for the following conditions acute lymphocytic

or nonlymphocytic leukemia advanced Hodgkins lymphoma advanced nonHodgkinslym phoma advanced neuroblastoma breast cancer multiple myeloma epithelial ovarian cancer
and testicular mediastinal retroperitoneal and ovarian germ cell tumors Related medical and hospital expenses of the donor are covered when the recipient is covered by this Plan
i 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 i Dialysis

i Chemotherapy radiation therapy and inhalation therapy
i Surgical treatment of morbid obesity
i Orthopedic devices such as braces foot orthotics
i Prosthetic devices such as artificial limbs and lenses following cataract removal
i Durable medical equipment such as wheelchairs and hospital beds
i Longterm ambulatory medicine and rehabilitative therapy
i Home health services of nurses and health aides including intravenous fluids and medica

tions when prescribed by your Plan doctor who will periodically review the program for continuing appropriateness and need

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 10 12
12 Page 13 14
OmniCare Health Plan 2000
Section 5 BENEFITS Medical and Surgical Benefits continued

i 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

Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization proce dures for congenital defects such as cleft lip and cleft palate and for medical or surgical pro
cedures 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 intraoral areas surrounding the teeth are not covered including any dental care involved in the treatment of temporomandibular joint TMJ pain dysfunction syndrome

Reconstructive surgery will be provided to correct a condition resulting from a functional defect or from an injury or surgery that has produced a major effect on the members appear
ance 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

Shortterm rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis for up to two consecutive months per condition if significant
improvement can be expected within two months you pay 10 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 selfcare and improved functioning in other activities of daily living

Diagnosis and treatment of infertility is covered you pay 10 The following type of artificial insemination is covered intracervical insemination ICI you pay 10 cost of donor sperm is
not covered Fertility medications are covered at a 50 copay in addition to the routine 2 prescription copay Other assisted reproductive technology ART procedures such as in
vitro fertilization and embryo transfer are not covered
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is provided at a Plan facility for as long as medically necessary you pay 10

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

i Reversal of voluntary surgicallyinduced sterility
i Surgery primarily for cosmetic purposes
i Homemaker services
i Transplants not listed as covered
i Hearing aids

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11 13
13 Page 14 15
OmniCare Health Plan 2000
Section 5 BENEFITS HospitalExtended Care Benefits

What is covered
Hospital care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are
hospitalized under the care of a Plan doctor You pay nothing All necessary services are covered including

i Semiprivate room accommodations when a Plan doctor determines it is medically necessary
the doctor may prescribe private accommodations or private duty nursing care i Specialized care units such as intensive care or cardiac care units

Extended care i The Plan provides a comprehensive range of benefits for up to 30 days per calendar year when fulltime 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

i Bed board and general nursing care
i 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 for up to 30 days Services include inpatient and outpatient care and family counsel
ing these services are provided under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness with a life expectancy of approximately six months or
less
Ambulance Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor Service

Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines there procedures 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 doctor determines that outpatient management is not medi cally appropriate See page 15 for nonmedical substance abuse benefits

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

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTOR
12 14
14 Page 15 16
OmniCare Health Plan 2000
Section 5 BENEFITS Emergency Benefits

What is a A medical emergency is the sudden and unexpected onset of a condition or an injury that
medical you believe endangers your life or could result in serious injury or disability and requires emergency 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 lifethreatening such as heart attacks
strokes poisonings gunshot wounds or sudden inability to breathe There are many other acute conditions that the Plan may determine are medical emergencies what
they all have in common is the need for quick action

Emergencies If you are in an emergency situation please call your primary care doctor In extreme within the emergencies if you are unable to contact your doctor contact the local emergency system
service area eg the 911 telephone service area 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 48 hours unless it was not reasonably possible to do so It is your responsibility to ensure that the Plan has been timely
notified
If you need to be hospitalized in a nonPlan facility the Plan must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to
notify the Plan within that time If you are hospitalized in nonPlan 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 nonPlan 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 followup care recommended by nonPlan 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 Nothing per hospital emergency room visit or nothing per urgent care center visit for emer gency services that are covered benefits of this Plan
Emergencies Benefits are available for any medically necessary health service that is immediately required outside the because of injury or unforeseen illness
service If you need to be hospitalized the Plan must be notified within 48 hours or on the first working
day following your admission unless it was not reasonably possible to notify the Plan within that time If a Plan doctor believes care can be better provided in a Plan hospital you will be
transferred when medically feasible with any ambulance charges covered in full
To be covered by this Plan any followup care recommended by nonPlan 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

13 15
15 Page 16 17
OmniCare Health Plan 2000
Section 5 BENEFITS Emergency Benefits continued

You pay Nothing per hospital emergency room visit or nothing per urgent care center visit for emer gency services that are covered benefits of this Plan
What is covered i Emergency care at a doctors office or an urgent care center i Emergency care as an outpatient or inpatient at a hospital including doctors services
i Ambulance service approved by the Plan

What is not covered i Elective care or nonemergency care i Emergency care provided outside the service area if the need for care could have been
foreseen before leaving the service area i Medical and hospital costs resulting from a normal fullterm delivery of a baby outside the
service area

Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency nonPlan providers care upon receipt of their claims Physician claims should be submitted on the HCFA 1500
claim form If you are required to pay for the services submit itemized bills and your receipts to the Plan along with an explanation of the services and the identification information from your
ID card Payment will be sent to you or the provider if you did not pay the bill unless the claim is denied If it is denied you will receive notice of the decision including the reasons for
the denial and the provisions of the contract on which denial was based If you disagree with the Plans decision you may request reconsideration in accordance with the disputed claims
procedure described on page 8

14 16
16 Page 17 18
OmniCare Health Plan 2000
Section 5 BENEFITS Mental ConditionsSubstance Abuse Benefits

Mental conditions
What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions including the treatment of
mental illness or disorders
i Diagnostic evaluation
i Psychological testing
i Psychiatric treatment including individual and group therapy
i Hospitalization including inpatient professional services

Outpatient Up to 52 outpatient visits to Plan doctors consultants or other psychiatric personnel each
care calendar year you pay nothing for visits 13 a 10 copay each for visits 452 all charges
thereafter

Inpatient Up to 45 days of hospitalization each calendar year you pay nothing for the first 45 days all
care charges thereafter Inpatient days can be exchanged for outpatient treatment at the rate of two
day treatments for each inpatient day

What is not i Care for psychiatric conditions that in the professional judgment of Plan doctors covered are not subject to significant improvement through relatively short term treatment
i 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 i Psychological testing that is not medically necessary to determine the appropriate treatment

of a shortterm psychiatric condition

Substance abuse
What is covered This Plan provides medical and hospital services such as acute detoxification services for the medical nonpsychiatric aspects of substance abuse including alcoholism and drug
addiction the same as for any other illness or condition and to the extent shown below the services necessary for diagnosis and treatment

Outpatient Up to 25 outpatient visits to Plan providers for treatment each calendar care year you pay
nothing for visits 13 a 10 copay each for visits 425 all charges thereafter

Inpatient Annual maximum of 30 days for substance abuse rehabilitation intermediate care program in
care an alcohol detoxification or rehabilitation center approved by the Plan You pay nothing during the benefit period all charges thereafter Inpatient days can be exchanged for outpatient

treatment at the rate of two day treatments for each inpatient day
What is not i Treatment that is not authorized by a Plan doctor covered

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTOR 15 17
17 Page 18 19
OmniCare Health Plan 2000
Section 5 BENEFITS Prescription Drug Benefits

Drug OmniCare like most HMOs has a list of drugs it dispenses with a prescription from a Plan
formulary doctor This list is called a drug formulary OmniCare reviews drugs to include in the formu lary The review is based on a comparison with similar drugs and clinical advantages of the

drug
Drugs not accepted into the formulary are covered when your Plan doctor receives approval from the Plan It is the Plan doctors responsibility to obtain the Plan authorization if the Plan
doctor fails to obtain the authorization and prescribes a nonformulary drug it will be covered for you by OmniCare

What is Prescription drugs prescribed by a Plan or referral doctor and obtained at a Plan pharmacy will covered be dispensed for up to a 34day supply You pay a 2 copay per prescription unit or refill
Drugs are prescribed by Plan doctors and dispensed in accordance with the Plans drug formulary Nonformulary drugs will be covered when prescribed by a Plan doctor
Covered medications and accessories include i Drugs for which a prescription is required by Federal law
i Oral contraceptive drugs up to a threemonth supply per refill may be obtained for a single
copay charge contraceptive diaphragms i Contraceptive devices and injectable contraceptives covered under Medical and Surgical

Benefits i Insulin
i Disposable needles and syringes needed for injecting covered prescribed medication
i Diabetic supplies including insulin syringes needles glucose test tablets and test tape

Benedicts solution or equivalent and acetone test tablets

Intravenous fluids and medications for home use implantable drugs such as Norplant and some injectable drugs such as Depo Provera are covered under Medical and Surgical
Benefits

Limited Benefits i Sexual dysfunction drugs have dispensing limitations you pay 50 copayment Contact Plan for details
i Fertility drugs are covered at 50 plus the 2 prescription copay

What is not i Drugs available without a prescription or for which there is a nonprescription equivalent
covered available i Drugs obtained at a nonPlan pharmacy except for outofarea emergencies

i Vitamins and nutritional substances that can be purchased without a prescription
i Medical supplies such as dressings and antiseptics
i Drugs for cosmetic purposes
i Drugs to enhance athletic performance
i Smoking cessation drugs and medications including nicotine patches gum and spray

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTOR
16 18
18 Page 19 20
OmniCare Health Plan 2000
Section 5 BENEFITS Dental Care Benefits

Accidental Restorative services and supplies necessary to promptly repair but not replace sound injury benefit natural teeth The need for these services must result from an accidental injury You pay
nothing
Dental benefits All services must be provided in a dentists office by an OmniCare Family Dentist or an OmniCare Specialty Dentist Benefits are provided for dental items and services that are
necessary for dental diagnosis and treatment as determined by OmniCare Family Dentist or an OmniCare Specialty Dentist A referral is not required for specialty services If enrollment in
OmniCare is terminated before the completion of a treatment plan benefits will not be provided after coverage under OmniCare has ended Members must demonstrate compliance to the
Soft Tissue Management Program by Family dentist before receiving periodontal sur gery
Copayments are applicable for each procedure as defined by the American Dental Association ADA Code Copayment must be paid on the date of service or the date the treatment
program begins Failure to do so will prevent future dental services from being received You pay a 10 copay per office visit plus each discount copay shown by the ADA Code Failure
to follow prescribed treatment or accidents occurring during the course of any treatment may result in additional charges A complete description of member copayments is listed below

ADA Member ADA Member
Code Service Copayment Code Service Copayment

Diagnostic Dentistry Diagnostic Dentistry continued 0999 Routine Office Visit 500 0274 XRay Bitewing Four Films No Charge
0120 Periodic Oral Exam No Charge 0330 XRay Panoramic No Charge 0140 Limited Oral Evaluation 0415 Bacterial Studies No Charge
Problem Focused 500 0425 Caries Susceptibility Tests No Charge 9440 O f fice Visit After Regular Hours 4000
0460 Pulp Vitality Tests No Charge 0150 Initial Exam No Charge
4999 Missed Appointment 0210 XRay Intraoral Complete Series Without 24 Hour Notice 2000

Including Bitewings No Charge 4999 Periodontal Probing in the Presence 0220 XRay Intraoral Periapical First Film No Charge
of Periodontal Disease 1500 0230 XRay Intraoral Periapical No Charge

Each Additional Film Diagnostic Services By Specialists
0240 XRay Intraoral Occlusal No Charge 0210 XRay Intraoral Complete Series 0250 XRay Extraoral First Film No Charge

Including Bitewings 3500 0260 XRay Extraoral Each Additional Film No Charge
0220 XRay Intraoral Periapical First Film 1000 0270 XRay Bitewing Single Film No Charge
0330 XRay Panoramic 3500 0272 XRay Bitewing Two Films No Charge

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTOR
17 19
19 Page 20 21
OmniCare Health Plan 2000
Section 5 BENEFITS Dental Care Benefits continued
ADA Member ADA Member Code Service Copayment Code Service Copayment

Preventive Dentistry 1110 Prophylaxis Adult Semiannually No Charge Restorative Dentistry continued
1120 Prophylaxis Child Semiannually No Charge 2940 Sedative Filling 6000 1203 Application of Topical Fluoride Child No Charge 2950 Core Buildup Including Any Pins 14500
1310 Nutritional Counseling No Charge 2951 Pin Retention 1330 Oral Hygiene Instruction No Charge Per Tooth in Addition to Restoration 3400
1351 Application of Sealant Per Tooth 1500 2952 Cast Post and Core in Addition to Crown 19600 1510 Space Maintainer Fixed Unilateral 6000 2954 Prefabricated Post and Core
1515 Space Maintainer Fixed Bilateral 6000 in Addition to Crown 17900 1520 Space Maintainer Removable Unilateral 9000 2960 Labial Veneer Laminate Chairside 15300
1525 Space Maintainer Removable Bilateral 9000 2962 Labial Veneer Porcelain Laminated Lab 38300 1550 Recement Space Maintainer No Charge 2980 Repair Crown 17000
1999 Additional Prophylaxis 2500 2999 Temporary Filling 500 2999 Cosmetic Bleaching Per Arch 25500
Restorative Dentistry 2999 Cosmetic Bleaching Both Arches 42500 2110 Amalgam One Surface Primary 4200
Endodontics 2120 Amalgam Two Surfaces Primary 5300 3110 Pulp Cap Direct 4300
2130 Amalgam Three Surfaces Primary 6500 3120 Pulp Cap Indirect 4300 2131 Amalgam Four Surfaces Primary 8000

3220 Pulpotomy 11100 2140 Amalgam One Surface Permanent 4600 3310 Root Canal Anterior 34000
2150 Amalgam Two Surfaces Permanent 6000 3320 Root Canal Bicuspid 40800 2160 Amalgam Three Surfaces Permanent 6800

3330 Root Canal Molar 46800 2161 Amalgam Four Surfaces Permanent 8500 3410 Apicoectomy Anterior 31500
2330 Resin One Surface Anterior 5300 3421 Apicoectomy Bicuspid First Root 37400 2331 Resin Two Surfaces Anterior 6800

3425 Apicoectomy Molar First Root 42500 2332 Resin Three Surfaces Anterior 8500 3426 Apicoectomy Each Additional Root 34000
2335 Resin Four or More Surfaces Anterior 11600 3430 Retrograde Filling Per Root 27200 2385 Resin One Surface Posterior Permanent 6000

3450 Root Amputation Per Root 38300 2386 Resin Two Surfaces Posterior Permanent 6800 3920 Hemisection Including Any Root Removal
2387 Resin Three Surfaces Posterior Permanent 11100 Not Including Root Canal Therapy 23000 2510 Inlay Metallic One Surface 25500

2520 Inlay Metallic Two Surfaces 28100 2530 Inlay Metallic Three Surfaces 34000 Periodontics
2543 Onlay Metallic Three Surfaces 42500 4210 Gingivoplasty or Gingivectomy 2544 Onlay Metallic Four or More Surfaces 45100 Per Quadrant 26400
2610 Inlay PorcelainCeramic One Surface 29800 4220 Gingival Curettage Per Quadrant 13600 2620 Inlay PorcelainCeramic Two Surfaces 36600 4260 Osseous Surgery Per Quadrant 36800
2630 Inlay PorcelainCeramic Three Surfaces 42500 4320 Provisional Splinting Intracoronal 17000 2740 Crown PorcelainCeramic 42500 4321 Provisional Splinting Extracoronal 21300
2750 Crown Porcelain to High Noble Metal 47600 4341 Periodontal Scaling and Root Planing 2751 Crown Porcelain to Base Metal 45100 Per Quadrant 11900
2752 Crown Porcelain to Noble Metal 46600 4355 Full Mouth Debridement 2790 Crown Full Cast High Noble Metal 49300 Complicated Cleaning 11100
2791 Crown Full Cast Base Metal 44200 4910 Periodontal Maintenance Procedures 8500
2792 Crown Full Cast Noble Metal 45900 4999 Periodontal Hygiene Instruction No Charge
2810 Crown 34 Cast Metallic 45100 Removable Prosthodontics 2910 Recement Inlay 1000

2920 Recement Crown 1000 5110 Complete Upper Denture 60400 2930 Prefabricated Stainless Steel Crown 5120 Complete Lower Denture 60400
Primary Tooth 17000
18 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTOR 20
20 Page 21 22
OmniCare Health Plan 2000
Section 5 BENEFITS Dental Care Benefits continued

ADA Member ADA Member Code Service Copayment Code Service Copayment
Removable Prosthodontics continued Fixed Prosthodontics continued 5130 Immediate Upper Denture 6721 Crown Resin with Base Metal Per Unit 34000
Excluding Reline 68000 6750 Crown Porcelain Fused to
5140 Immediate Lower Denture High Noble Metal Per Unit 47600
Excluding Reline 68000 6751 Crown Porcelain Fused to Base Metal
5211 Upper Partial Denture Resin Base Per Unit 45100 Including Clasps etc 57000 6752 Crown Porcelain Fused to Noble Metal

5212 Lower Partial Denture Resin Base Per Unit 46800 Including Clasps etc 57000 6780 Crown 34 Cast High Noble Metal
5213 Upper Partial Denture Per Unit 45100 Cast Metal FrameworkAcrylic Base 64600 6790 Crown Full Cast High Noble Metal
5214 Lower Partial Denture Per Unit 49300 Cast Metal FrameworkAcrylic Base 64600 6791 Crown Full Cast Base Metal Per Unit 44200
5410 Adjust Complete Denture Upper 6000 6792 Crown Full Cast Noble Metal Per Unit 45900 5411 Adjust Complete Denture Lower 6000 6930 Recement Bridge 7700
5421 Adjust Partial Denture Upper 6000 6940 Stress Breaker 12800 5422 Adjust Partial Denture Lower 6000 6950 Precision Attachment 14500
5510 Repair Broken Complete Denture Base 9400 6980 Bridge Repair 17000 5610 Repair Resin Denture Base 8500 6999 Resin Bonded Bridge Pontic Per Unit 42500
5620 Repair Cast Framework 22100 Oral Surgery 5630 Repair or Replace Broken Clasps 20400
7110 Extraction Single Tooth 6000 5640 Repair Broken Teeth Per Tooth 7700 7120 Extraction Each Additional Tooth 6000
5650 Add Tooth to Existing Partial Denture 11100 7130 Root Removal Exposed Roots 7700 5730 Reline Complete Upper Denture Chairside 23000

7210 Surgical Removal of Erupted Tooth 5731 Reline Complete Lower Denture Chairside 23000 Bone RemovalSectioning 10200
5740 Reline Upper Partial Denture Chairside 18700 7220 Removal of Impacted Tooth Soft Tissue 12800 5741 Reline Lower Partial Denture Chairside 18700

7230 Removal of Impacted Tooth Partial Bony 15300 5750 Reline Complete Upper Denture Lab 24700 7240 Removal of Impacted Tooth Complete Bony18700
5751 Reline Complete Lower Denture Lab 24700 7241 Removal of Impacted Tooth 5760 Reline Upper Partial Denture Lab 23100

5761 Reline Lower Partial Denture Lab 23100 Complete Bony with Complications 21300 5850 Tissue Conditioning Upper Denture 12800 7250 Surgical Removal of Residual Roots
5851 Tissue Conditioning Lower Denture 12800 Cutting Procedure 28100 5862 Precision Attachment 13600 7270 Tooth ReimplantationS tabilization 29800
7281 Surgical Exposure Per Tooth 23800
Fixed Prosthodontics 7310 Alveoloplasty in Conjunction 6210 Pontic Cast High Noble Metal Per Unit 49300 With Extractions Per Quadrant 12800

6211 Pontic Cast Base Metal Per Unit 44200 7320 Alveoloplasty Not in Conjunction 6212 Pontic Cast Noble Metal Per Unit 45900 with Extractions Per Quadrant 5500
6240 Pontic Porcelain Fused to 7470 Removal of Exostosis 34000 High Noble Metal Per Unit 47600 7510 Incision and Drainage of Abscess 12800
6241 Pontic Porcelain Fused to Base Metal 7910 Simple Suture No Charge Per Unit 45100 7960 Frenectomy 21300
6242 Pontic Porcelain Fused to Noble Metal Orthodontics Per Unit 46800
8999 Diagnostic Workup with Radiographs 6251 Pontic Resin with Base Metal Per Unit 34000 Models 22100
6545 Resin Bonded Retainer Per Unit 44200

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTOR 19 21
21 Page 22 23
OmniCare Health Plan 2000
Section 5 BENEFITS Dental Care Benefits continued

ADA Member ADA Member Code Service Copayment
Code Service Copayment

Orthodontics continued Orthodontics continued 8210 Removable Appliance Therapy 56000 8999 Adjusting Retainer by Report No Charge
8220 Fixed Appliance Therapy 50000 8999 Elastics by Report No Charge 8030 Limited Orthodontic Treatment of 8999 Final Orthodontic Records by Report No Charge
Adolescent Dentition Class I II 8999 Reattach Brackets and Bands by Report Malocclusion by Family Dentist 95200 Limit 3 Times No Charge
8030 Limited Orthodontic Treatment of 8999 Replace Broken Ligature Wires Adolescent Dentition Class I II by Report Limit 3 Times No Charge
Malocclusion by Board Eligible Specialist 119000 8999 Premium Transparent Brackets 8040 Limited Orthodontic Treatment of Per Arch by Report 51000
Adult Dentition Class I II Malocclusion by Family Dentist 95200
Other Services 8040 Limited Orthodontic Treatment of 9210 Local Anesthesia

Adult Dentition Class I II without Operative Procedures No Charge
Malocclusion by Board Eligible Specialist 129000 9215 Local Anesthesia 8080 Class I II Malocclusion by with Operative Procedures No Charge

Family Dentist Child 190000 9220 General Anesthesia 13600 8080 Class I II Malocclusion by 9230 Analgesia Nitrous Oxide 4300
Board Eligible SpecialistChild 238000 9240 IV Sedation 13600 8090 Class I II Malocclusion by 9310 Consultation Appointment Diagnostic
Family Dentist Adult 230000 Service Provided by Dentist Other 8090 Class I II Malocclusion by Than Practitioner Providing Treatment 6000
Board Eligible SpecialistAdult 258000 9940 Occlusal Guards 30600 8660 Preorthodontic Treatment Visit 3500 9951 Occlusal Adjustment Limited 16200
8680 Retainer Each Arch 9952 Occlusal Adjustment Complete 32300 Post Treatment Stabilization 16200

Dental Emergency In case of a dental emergency a member should contact their Family Dentist directly If the Family
Procedures Dentist is unavailable for emergency care within 24 hours of the onset of the dental emergency as verified by the Plan members may obtain emergency services from any licensed dentist to prevent their

dental health from being jeopardized palliative treatment to control pain bleeding or infection and return to their Family Dentist for continuing treatment In order to receive reimbursement for fees paid
less any applicable copayment for services provided and the after hours visit ADA code 9440 copayment 4000 the following steps must be taken if the member is outside of the service area

1 The member must notify the Plan or their Family Dentist of their dental emergency within 48 hours of the onset of the emergency or as soon as it is reasonably possible to do so and
receive authorization for continued care if warranted
2 The written request for reimbursement with receipts must be received by the Plan within 30 days of the onset of the emergency

Copayments listed for metallic restorations do not include the cost of gold for ADA codes 2510 2520 2530 2543 2544 2750 2752 2790 2792 2810 6210 6212 6240 6242 6750 6752 6780 6790 and 6792

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTOR 20 22
22 Page 23 24
OmniCare Health Plan 2000
Section 5 BENEFITS Dental Care Benefits continued

Dental Emergency Procedures continued
Orthodontic Treatment is limited as follows a Minor treatment of tooth guidanceInterceptive orthodontia for 18 consecu
tive months b Active orthodontic treatment from time of banding for 24 consecutive
months c Retention treatment for 18 consecutive months
d Ongoing treatment past the time frames above is subject to additional fees determined by the Orthodontist or Family Dentist performing orthodontics

What is not covered i Services by nonparticipating providers i Dental procedures and consultations for services not listed as covered
i Dental services started or rendered after termination of coverage in this Plan
i Services determined by plan dentist not to be necessary for dental diagnosis and

treatment i Medical costs associated with dental procedures except for services covered

under Medical and Surgical and HospitalExtended Benefits i Extractions for diseased wisdom teeth ie severe decay odontogenic cysts
chronic pericoronitis and infection i Procedures for children under four years of age
i Specialists required for behavior modifications ie physical restraint sedation or
other method of control i Repair or replacement of dentures or appliances within 3 years except when

required due to illness i Replacement of loss or stolen dentures appliances or bridgework
i Orthodontic treatment which involves therapy for myofunctional problems TMJ
dysfunctions micrognathia macroglossia or hormonal imbalances causing growth and developmental abnormalities except for cleft palate

i Orthodontic cases other than Type I or II malocclusions

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 to provide a written lens prescription
may be obtained from Plan providers You pay 10 nothing
What is not covered i Corrective eyeglasses and frames or contact lenses including the fitting of the lenses
i Eye exercises

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTOR
21 23
23 Page 24 25
OmniCare Health Plan 2000
Section 6 General Exclusions Things We Dont 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 nonPlan providers except for authorized referrals or emergencies see Emergency Benefits or eligible self
referral services
Experimental or investigational procedures treatments drugs or devices
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

22 24
24 Page 25 26
OmniCare Health Plan 2000
Section 7 Limitations Rules That Affect Your Benefits

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

If you are eligible for Medicare you may enroll in a MedicareChoice 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
MedicareChoice plan when one is available in your area For information on suspending your
FEHB enrollment and changing to a MedicareChoice plan contact your retirement office If you
later want to reenroll 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 MedicareChoice 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 MedicareChoice plans contact your local Social Security Administration SSA
office or request it from SSA at 18006386833

Other group When anyone has coverage with us and with another group health plan it is called double coverage
insurance You must tell us if you or a family member has double coverage You must also send us documents
coverage 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 which
ever 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 provide them In that case we will make all reasonable efforts to provide you with necessary care
control

When others When you receive money to compensate you for medical or hospital care for injuries or illness that
are responsible another person caused you must reimburse us for whatever services we paid for We will cover the
for injuries cost of treatment that exceeds the amount you received in the settlement If you do not seek

23 25
25 Page 26 27
OmniCare Health Plan 2000
Section 7 Limitations Rules That Affect Your Benefits continued

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 We do not cover services that
compensation You need because of a workplacerelated disease or injury that the Office of Workers Compensa
tion 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 We do not cover services and supplies that a local State or Federal Government agency directly
Government or indirectly pays for
Agencies

24 26
26 Page 27 28

OmniCare 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
your HMO 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 OPMs website wwwopmgov lists the specific types of information that
we must make available to you

If you want specific information about us call 8004776664 or write to the Plan at 1155
Brewery Park Blvd Detroit Michigan 48207 You may also contact us by fax at 3133937944
or visit our website at wwwochpcom

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 dont 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

What types of SelfOnly 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 may
family and me also get coverage for a disabled child 22 years of age or older who is incapable of self
support

If you have a Self Only enrollment you may change to a Self and Family enrollment if you
marry give birth or add a child to your family You may change your enrollment 31 days before
to 60 days after you give birth or add the child to your family The benefits and premiums for
your Self and Family enrollment begin on the first day of the pay period in which the child is
born or becomes an eligible family member

25 27
27 Page 28 29
OmniCare Health Plan 2000
Section 8 FEHB FACTS continued Your employing or retirement office will not notify you when a family member is no longer

eligible to receive health benefits nor will we Please tell us immediately when you add or
remove family members from your coverage for any reason including divorce

If you or one of your family members is enrolled in one FEHB plan that person may not be
enrolled in another FEHB plan

Are my medical and We will keep your medical and claims information confidential Only the following will have
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 coordinating benefit
payments and subrogation claims
Law enforcement officials when investigating andor 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 SF2809 or the OPM annuitant confirmation letter until you receive your ID card You
can also use an Employee Express confirmation letter

What if I paid a Your old plans deductible continues until our coverage begins
deductible under
my old plan

Preexisting 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
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
spouse coverage benefits under your former spouses enrollment But you may be eligible for your own FEHB

26 28
28 Page 29 30
OmniCare Health Plan 2000
Section 8 FEHB FACTS continued

coverage under the spouse equity law If you are recently divorced or are anticipating a
divorce contact your exspouses 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 7927 which describes TCC and the RI 705 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 2percent administrative charge The govern

ment does not share your costs
You receive another 31day extension of coverage when your TCC enrollment ends unless
you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits

How do I enroll If you leave Federal service your employing office will notify you of your right to enroll under
in TCC TCC You must enroll within 60 days of leaving or receiving this notice whichever is later

Children You must notify your employing or retirement office within 60 days after your child is
no longer an eligible family member That office will send you information about enrolling in
TCC You must enroll your child within 60 days after they become eligible for TCC or receive
this notice whichever is later

Former spouses You or your former spouse must notify your employing or retirement office
within 60 days of one of these qualifying events

Divorce
Loss of spouse equity coverage within 36 months after the divorce

Your employing or retirement office will then send your former spouse information about
enrolling in TCC Your former spouse must enroll within 60 days after the event which
qualifies them for coverage or receiving the information whichever is later

27 29
29 Page 30 31
OmniCare Health Plan 2000
Section 8 FEHB FACTS continued
Note Your child or former spouse loses TCC eligibility unless you or your former spouse
notify your employing or retirement office within the 60day deadline

How can I You may convert to an individual policy if
convert to
individual Your coverage under TCC or the spouse equity law ends If you canceled your coverage or
coverage 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 dif fer 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 preexisting 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 that indicates how long you have been enrolled with us You can use this certificate when
Group Health getting health insurance or other health care coverage You must arrange for the other
Plan Coverage 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

28 30
30 Page 31 32
OmniCare 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 us at 8004776664 and explain the situation
If we do not resolve the issue call or write

THE HEALTH CARE FRAUD HOTLINE 2024183300
US Office of Personnel Management Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400 Washington DC 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

29 31
31 Page 32 33
OmniCare Health Plan 2000
Notes

30 32
32 Page 33 34
OmniCare Health Plan 2000
Notes

31 33
33 Page 34 35
OmniCare Health Plan 2000
Notes

32 34
34 Page 35 36
OmniCare Health Plan 2000
Summary of Benefits for OmniCare Health Plan2000

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 paysprovides Page Inpatient care Hospital Comprehensive range of medical and surgical services without dollar or day
limit Includes inhospital doctor care room and board general nursing care private room and private nursing care if medically necessary diagnostic
tests drugs and medical supplies use of operating room intensive care and complete maternity care You pay nothing 12

Extended care All necessary services up to 30 days per year You pay nothing 12
Mental Diagnosis and treatment of acute psychiatric conditions for up to conditions 45 days of inpatient care per year You pay nothing 15

Substance abuse Up to 30 days per year for substance abuse rehabilitation You pay nothing 15
Outpatient Comprehensive range of services such as diagnosis and treatment of illness
care or injury including specialists care preventive care wellbaby care periodic checkups and routine immunizations laboratory tests and Xrays complete

maternity care You pay 10 10
Home health All necessary visits by nurses and health aides You pay nothing 10 care

Mental Up to 52 outpatient visits per year You pay nothing for visits 13 a 10 copay conditions per visit for visits 452 15
Substance abuse Up to 25 outpatient visits per year You pay nothing for visits 13 a 10 copay per visit forvisits 425 15
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay nothing for services that are covered by this Plan 1314
Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 2 copay per prescription unit or refill 16
Dental care Accidental injury benefit you pay nothing Preventative and restorative dental care you pay scheduled copays 1721
Vision care One refraction annually you pay 10 21

33 35
35 Page 36
OmniCare Health Plan 2000
2000 Rate Information for
OmniCare Health Plan

NonPostal rates apply to most nonPostal 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 US 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 702 to deter
mine which rate applies to you
Postal rates do not apply to noncareer 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

NonPostal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Code Govt Your Govt Your USPS Your USPS Your Enrollment Share Share Share Share Share Share Share Share Share

Self Only KA1 5308 1769 11501 3833 6281 796 6281 796 Self and Family KA2 13271 4424 28754 9585 15704 1991 15704 1991

34 36

Page Navigation Panel

1 2 3 4 5 6 7 8 9
10 11 12 13 14 15 16 17 18 19
20 21 22 23 24 25 26 27 28 29
30 31 32 33 34 35 36