Pages 1--33 from medic

Texas Health Choice L C 2000 Formerly HMO Texas L C
A Health Maintenance Organization

Serving Dallas and Fort Worth Areas
Houston and Golden Triangle Areas

Enrollment in this Plan is limited see pages 5 8 for requirements
For changes in benefits see pages 3 5

Enrollment code
UK1 Self only
UK2 Self and family

Region includes the Dallas Fort Worth areas

Enrollment code
2T1 Self only
2T2 Self and family

Region includes the Greater Houston Golden Triangle areas

Visit the OPM website at http www opm gov insure
and
This Plan's website at http www sierrahealth com

Authorized for distribution by the
United State Office of Personal Management
Retirement and Insurance Service RI 73 658 1
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Texas Health Choice L C 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 5
Section 4 What to do if we deny your claim or request for service 9
Section 5 Benefits 11
Section 6 General exclusions Things we don't cover 21
Section 7 Limitations Rules that affect your benefits 21
Section 8 FEHB facts 22
Department of Defense FEHB Demonstration Project 26
Inspector General Advisory Stop Healthcare Fraud 28
Summary of benefits Inside back cover
Premiums Back cover

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Texas Health Choice L C 2000
Introduction
Texas Health Choice L C
9330 Amberton Parkway
Dallas Tx 75243

Texas Health Choice L C
11011 Richmond Suite 900
Houston Texas 77042

This brochure describes the benefits you can receive from Texas Health Choice under its contract with the Office of Personnel
Management OPM as authorized by the Federal Employees Health Benefits FEHB law This brochure is the official statement of
benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this brochure If you are
enrolled for Self and Family coverage each eligible family member is also entitled to these benefits

OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on
pages 3 5 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 Texas Health Choice 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 but some of your benefits have changed in the year 2000 You will find
new benefit description language next year

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Texas Health Choice L C 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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Texas Health Choice L C 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 shots 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 when you receive
services 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 primary care
changes 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

You may review and obtain copies of your medical records on request You may ask that a physician
amend a record that is not accurate relevant or complete If the physician does not amend your record
you may add a brief statement to the record

If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This
screening is for colorectal cancer

Changes to the Your share of the non postal premium will increase by 0.2 percent for Self Only or 3.9 percent for
Dallas Plan Self and Family The out of pocket maximum was 1,500 per individual and 3,900 per family but it has decreased

to 600 per individual and 1,200 per family
The oral surgical services benefit has been improved and now includes coverage for treatment required to stabilize sound natural teeth the jawbones or surrounding tissues after an Accidental

Injury when the treatment is initiated within the first ten 10 days This includes but is not limited
to coverage for the following incision and drainage excision of broken sound and natural teeth or
tooth stabilization through splinting
Short term inpatient rehabilitation services were covered at no charge for physical therapy and 20 of charges for chronic pain management speech therapy and occupational therapy but now each

therapy will be covered at no charge limited to two months or 30 visits whichever is greater per
medical episode
Short term outpatient rehabilitation services were covered at 5 a visit for physical therapy and 20 of charges for chronic pain management speech therapy and occupational therapy but now each

therapy will be covered at 10 a visit limited to two months or 30 visits whichever is greater per
medical episode

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Texas Health Choice L C 2000
Section 2 How we change for 2000 continued
Changes to the The benefits for hospice services have been clarified and now include the following no charge for
Dallas Plan inpatient hospice care 10 for bereavement counseling up to 5 visits or 500 whichever is less and continued no charge for inpatient and outpatient respite care The limitation on bereavement services is a year

2000 addition
The urgent care facility copay has increased from 5 a visit to 25 a visit
The outpatient mental health benefit was 20 a visit up to 30 visits per year but the coverage has improved to 20 a visit for individual therapy and 10 a visit for group therapy with a combined

calendar year maximum of 40 visits
The inpatient calendar year benefit maximum for treatment of substance abuse has decreased from 45 days to 30 days

The outpatient calendar year benefit maximum for treatment of substance abuse has decreased from unlimited visits to 40 visits
The copay for generic prescription drugs has decreased from 10 to 6
The copay for brand name prescription drugs has increased from 10 to 12
The mail order drug copay will remain at two times the generic or brand name copay However the supply will be increased from a 60 day supply to a 90 day supply

Non formulary drugs were covered at the appropriate generic or brand name copay if the member's provider specified that no substitutions were permitted for the written prescriptions Now the nonformulary
drug copay has changed to 50 of charges for any non formulary drug regardless of
whether substitutions are permitted
Injectable and internally implanted time release medications except Norplant were covered at 5 times the number of months the medication was to be effective not to exceed 200 This benefit has

changed so that you will now simply pay the appropriate generic or brand name copay depending on
the medication prescribed

Changes to the Your share of the non postal premium has decreased by 7.1 percent for Self Only or 4.7 percent for
Houston Plan Self and Family The point of service benefit is no longer available

The sterilization benefit was no charge Now there is a charge of 75 for a vasectomy and 200 for a tubal ligation
Diagnosis and treatment of infertility was covered at 10 a visit Now copays have increased to 50 of charges per visit
Previously we did not provide coverage for infertility drugs Now we will provide coverage with a copay of 50 of charges
The Skilled Nursing Facility benefit was unlimited Now it will have a 100 days per calendar year limit
The substance abuse outpatient lifetime maximum has been eliminated
Durable medical equipment was covered with a 30 copay Now the copay has been lowered to 20 of charges

Orthotic and prosthetic devices were covered at no charge Now the copay has increased to 20 of charges
The copay for self management education and training of diabetics has increased from no charge to 10 a visit
The copay for brand name drugs has decreased from 15 to 12
Injectable and time released medications except Norplant were covered same as any other drug without a benefit limit Now they are covered at the appropriate generic or brand name copay times

the number of months the medication will be effective not to exceed 200
The copay for erectile dysfunction drugs has increased from the appropriate generic or brand name copay to 50 of charges

The dental prophylaxis cleaning benefit copay has decreased from 20 a visit to 10 a visit
The dental bitewing X ray benefit copay has decreased from 10 a visit to no charge

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Texas Health Choice L C 2000
Section 2 How we change for 2000 continued
Changes to the The dental complete series X ray benefit copay has decreased from 25 a visit to no charge when
Houston Plan reasonable and necessary for dental diagnosis and treatment continued A dental emergency oral exam benefit has been added with a 15 copay per visit inside the service

area and 25 copay per visit outside the service area
A discount of 15 has been added for additional dental services not covered
A vision benefit has been added to the core medical plan and taken out of the non FEHBP benefit The old plan offered discounts only Now the core vision plan exam is 10 a visit and the glasses

frames and contact lenses are 20 of charges

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 practice
Plan's service
area Our service area is comprised of the following full counties in North Central Texas

Collin Dallas Denton Ellis Hood Hunt Johnson Kaufman Parker Rockwall Tarrant and Wise

Our service area is comprised of the following full counties in the Houston and Golden Triangle Areas
Austin Brazoria Chambers Colorado Fort Bend Galveston Grimes Harding Harris Jefferson
Liberty Matagorda Montgomery Orange San Jacinto Waller and Wharton

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 travels frequently or lives away from home part of the year you
should be aware that benefits for care outside the service area are restricted to emergency care and care
received at contracting providers in other areas of the continental United States Contact the Plan for
further details on services available from providers that have a contractual arrangement with Texas
Health Choice L C or an affiliate organization

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 either a copayment a set dollar amount or
pay for coinsurance a set percent of charges Please remember you must pay this amount when you receive
services services except for the following services prenatal care routine immunizations and boosters from birth to 6 years of age laboratory and X ray services complex diagnostic services physician house calls

home health care inpatient hospital services inpatient surgical services anesthesia outpatient surgical
services short term inpatient rehabilitation services skilled nursing facility care inpatient hospice care
respite care inpatient mental health services inpatient substance abuse services transplant services and
diabetic supplies

After you pay 600 in copayments or coinsurance for one family member or 1,200 for two or more
family members you do not have to make any further payments for certain services for the rest of the
year This is called a catastrophic limit However copayments or coinsurance for your prescription
drugs and dental services do not count toward these limits and you must continue to make these
payments

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Texas Health Choice L C 2000
Section 3 How to get benefits continued
Do I have to Be sure to keep accurate records of your copayments and coinsurance since you are responsible for
submit claims informing us when you reach the limits You normally won't have to submit claims to us unless you receive emergency services from a provider

who doesn't contract with us If you file a claim please send us all of the documents for your claim as
soon as possible You must submit claims by December 31 of the year after the year you received the
service Either OPM or we can extend this deadline if you show that circumstances beyond your control
prevented you from filing on time

Who provides Texas Health Choice L C offers comprehensive health care coverage on a pre paid basis at Plan
my health care facilities conveniently located throughout the Dallas Ft Worth metropolitan area and through referral
in Dallas specialists hospitals and other providers in the community All care should be received at these facilities and from these providers except in medical emergencies

As a mixed model plan Texas Health Choice L C contracts with doctors who practice under an
Independent Practice Association IPA in medical centers or groups of physicians most notably The
Medical Group of Texas or with individual physicians to provide your care Medical care is provided
through doctors nurse practitioners and other skilled medical personnel working as medical teams for
consultation and treatment Other necessary medical services such as physical therapy laboratory and
X ray services are also available at Plan facilities Hospital care is provided through the Plan at several
local community hospitals

You must choose a primary care doctor when you choose this Plan The Texas Health Choice provider
directory lists primary care providers with their locations and phone numbers Primary care doctors
generally include family practitioners pediatricians and internists With one exception for OB GYN
doctors the primary care doctor you select will determine which set of specialty physicians you may
access For example if you select a primary care doctor affiliated with our contracted IPA you will only
be able to access specialists affiliated with the IPA and not The Medical Group of Texas

In addition to selecting a primary care doctor we also request that female members over the age of 14
select an OB GYN at the same time they select a primary care doctor OB GYN doctors may be accessed
directly without referral from a primary care provider Also members may select an OB GYN from any
of Texas Health Choice's network of providers regardless of whether the OB GYN is part of their
primary care provider's network

Who Provides This plan has been approved as an Individual Practice Association IPA model plan Texas Health
My Health Care Choice's Physician network is comprised of sixteen 16 contracted IPAs The contracted IPAs consist
in Houston of over 375 Primary Care Physicians PCPs and 1,000 specialist physicians The Plan also contracts with 34 area hospitals

You must choose a primary care doctor when you choose this Plan The Texas Health Choice provider
directory lists primary care providers with their locations and phone numbers Primary care doctors
generally include family practitioners pediatricians and internists You may select one of the Plan's
PCPs from any one of the IPAs The primary care doctor you select will determine which set of specialty
physicians you may access

In addition to selecting a primary care doctor we also request that female members over the age of 14
select an OB GYN at the same time they select a primary care doctor OB GYN doctors may be accessed
directly without referral from a primary care provider

Texas Health Choice L C offers comprehensive health care coverage on a pre paid basis at Plan
contracted specialists hospitals and other providers conveniently located throughout the Houston and
Golden Triangle area All care should be received at contracted facilities and from contracted providers
except in medical emergencies

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Texas Health Choice L C 2000
Section 3 How to get benefits continued
What do I do if Call us We will help you select a new one
my primary
care physician
leaves the Plan

What do I do if Talk to your Plan doctor If you need to be hospitalized your primary care provider or specialist will
I need to go into make the necessary hospital arrangements and supervise your care
the hospital If you are in an emergency situation and need to be hospitalized please contact us at the number listed on

the back of your membership card

If you need to be hospitalized in a non Plan facility the Plan must be notified within 48 hours or as soon
as possible following your admission 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

What do I do if First call our Member Service department at 1 800 466 8397 If you are new to the FEHB Program we
I'm in the will arrange for you to receive care If you are currently in the FEHB Program and are switching to us
hospital when I your former plan will pay for the hospital stay until
join this 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 Talk to your doctor Your primary care provider will arrange for your referral to a specialist It is the
specialty care responsibility of your primary care provider to obtain any necessary authorizations from the Plan before referring you to a specialist or making arrangements for hospitalization Services of other Plan providers

and non Plan providers are covered only when there has been a referral by your primary care provider

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 and must request approval from a Texas Health Choice Medical
Director

What do I do if Your primary care physician will decide what treatment you need If they decide to refer you to a
I am seeing a specialist ask if you can see your current specialist If your current specialist does not participate with
specialist when I us you must receive treatment from a specialist who does Generally we will not pay for you to see a
enroll 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 receive
my specialist services from your current specialist until we can make arrangements for you to see someone else
leaves the Plan

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Texas Health Choice L C 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 continue
have a serious seeing your provider for up to 90 days after we notify you that we are terminating our contract with the
illness and my provider unless the termination is for cause If you are in the second or third trimester of pregnancy
provider leaves you may continue to see your OB GYN until the end of your postpartum care
the Plan or this You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and
Plan leaves the you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic
Program condition or are in your second or third trimester Your new plan will pay for or provide your care for up

to 90 days after you receive notice that your prior plan is leaving the FEHB Program If you are in your
second or third trimester your new plan will pay for the OB GYN care you receive from your current
provider until the end of your postpartum care

How do you Your physician must get our approval before sending you to a hospital referring you to a specialist or
authorize recommending follow up care Before giving approval we consider if the service is medically necessary
medical and if it follows generally accepted medical practice
services

How do you In order to keep pace with developments in new medical technology and to ensure that members have
decide if a access to safe and effective care Texas Health Choice has adopted a formal process to assess new and
service is emerging medical discoveries before they are included in our member benefit package This process
experimental or includes the review of new medical procedures drugs devices and new applications of already existing
investigational technologies If the medical breakthrough passes all the rigorous medical tests and is of benefit to the member it is considered as a diagnostic or treatment option for the member

New medical technology is reviewed against specific criteria and clinical research for its effectiveness
Texas Health Choice solicits input from local and national specialties during the review process

The new technology must
be approved by the appropriate government regulatory body for example Food and Drug Administration approves new pharmaceutical drugs

demonstrate a positive effect and improve health outcomes
be as beneficial as any established alternatives
be able to demonstrate improvement outside the investigational setting
demonstrate cost effectiveness

Requests for review of a NEW medical technology review may be submitted by physicians health plan
members and other interested parties

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Texas Health Choice L C 2000
Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording in 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

What if you If your condition is serious or life threatening call us We will work with you to expedite the review of
have denied my your claim Serious or life threatening conditions are ones that may cause permanent loss of bodily
request for care functions or death if they are not treated as soon as possible
and my
condition is
serious or life
threatening

What if you Call us at 202 606 0755 and we will expedite our review
have a serious
or life
threatening
condition and
you haven't
responded to my
request for
service

When may I ask You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal OPM
OPM to review will determine if we correctly applied the terms of our contract when we denied your claim or request for
a denial service

Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold our initial
time limits 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 do not answer within 30 days In
this case OPM must receive your request within 120 days of the date we asked you for additional
information

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Texas Health Choice L C 2000
Section 4 What to do if we deny your claim or request for service continued
What do I send Your request must be complete or OPM will return it to you You must send the following information
to OPM 1 A statement about why you believe our decision is wrong based on specific benefit provisions in

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

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

Who can make 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 Send your request for review to Office of Personnel Management Office of Insurance Programs
mail my Contract Division 3 P O Box 436 Washington D C 20044
disputed claim
to OPM

What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our decision
upholds the your only recourse is to sue
Plan's 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 Federal law governs your lawsuit benefits and payment of benefits The Federal court will base its
apply if I file a review on the record that was before OPM when OPM made its decision on your claim You may
lawsuit recover only the amount of benefits in dispute

You or a person acting on your behalf may not sue to recover benefits on a claim for treatment
services supplies or drugs covered by us until you have completed the OPM review procedure described
above

Your records Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and us
and the Privacy to determine if our denial of your claim is correct The information OPM collects during the review
Act process becomes a permanent part of your disputed claims file and is subject to the provisions of the Freedom of Information Act and the Privacy Act OPM may disclose this information to support the

disputed claim decision If you file a lawsuit this information will become part of the court record

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Texas Health Choice L C 2000
Section 5 BENEFITS
Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits you pay a 10 office visit copay but no
additional copay for laboratory tests and X rays Within the service area house calls will be provided if
in the judgment of the Plan doctor such care is necessary and appropriate you pay nothing for a doctor's
house call and home visits by nurses and health aides

Copayments for surgery are as shown under Limited benefits
The following services are included and are subject to the office visit copay unless stated otherwise
Preventive care including well baby care and periodic check ups
Mammograms are covered as follows for women age 35 through age 39 one mammogram during these five years for women age 40 through age 49 one mammogram every one or two years for

women age 50 through age 64 one mammogram every year and for women age 65 and above one
mammogram every two years You pay nothing In addition to routine screening mammograms are
covered when prescribed by the doctor as medically necessary to diagnose or treat your illness
Fecal occult blood test for members age 40 and over Sigmoidoscopy screening every 5 years starting at age 50

Routine immunizations and boosters including inactivated poliovirus vaccine IPV at 2 and 4 months of age You pay nothing
Consultations by specialists
Diabetic education and training You pay nothing
Diagnostic procedures such as laboratory tests and x rays You pay nothing
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor You pay nothing for office visits to Plan doctors for prenatal and

postnatal care Complete obstetrical maternity care for covered females including all prenatal
delivery and postnatal care by a Plan doctor The mother at her option may remain in the hospital
up to 48 hours after a regular delivery and 96 hours after a caesarean delivery Inpatient stays will
be extended if medically necessary If enrollment in the Plan is terminated during pregnancy
benefits will not be provided after coverage under the Plan has ended Ordinary nursery care of the
newborn child during the covered portion of the mother's hospital confinement for maternity will be
covered under either a Self Only or Self and Family enrollment other care of an infant who requires
definitive treatment will be covered only if the infant is covered under a Self and Family enrollment
Voluntary sterilization and family planning services You pay 75 for a vasectomy and 200 for a tubal ligation

Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including testing and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart kidney and liver transplants lung single or double heart lung kidney pancrease allogeneic donor bone marrow transplants autologous bone marrow transplants autologous stem

cell and peripheral stem cell support and autologous bone marrow transplants 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
Related medical and hospital expenses of the donor are covered when the recipient is covered by this
Plan
Women who undergo mastectomies may at their option have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure

Dialysis You pay nothing

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Texas Health Choice L C 2000
Section 5 BENEFITS continued
What is covered Chemotherapy radiation therapy and inhalation therapy You pay nothing continued Surgical treatment of morbid obesity
Prosthetic devices such as artificial limbs and lenses following cataract removal initial device covered only Covered prostheses also includes breast prostheses including the surgical bra for an
external prosthesis following a mastectomy We will also cover necessary replacement prostheses
and bras as well You pay 20 of charges
Durable medical equipment and diabetic equipment You pay 20 of charges
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

Blood and blood derivatives
Surgical procedures are no charge for all procedures except those performed in the doctor's office which alone are subject to a 10 copayment per procedure in addition to the office visit copayment

however sterilizations performed in a doctor's office are 75 for a vasectomy and 200 for a tubal
ligation Inpatient surgical procedures are no charge

Limited benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or surgical procedures
occurring within or adjacent to the oral cavity or sinuses including but not limited to treatment of
fractures and excision of tumors and cysts All other procedures involving the teeth or intra oral
areas surrounding the teeth are not covered including shortening of the mandible or maxillae for
cosmetic purposes correction of malocclusion and any dental care involved in 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 member's appearance and if the

condition can reasonably be expected to be corrected by such surgery A patient and their attending
physician will decide whether or not to have breast reconstruction surgery following a medically
necessary mastectomy including whether or not to have surgery on the other breast in order to
produce a symmetrical appearance
Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis for up to two months per condition or 30 visits whichever is greater per medical

episode 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 you pay nothing for inpatient sessions
and a 10 copay per outpatient session
Subject to the benefit maximums outlined above medically necessary physical therapy occupational
therapy and speech therapy will not be denied limited or terminated and will continue to be covered
provided your condition improves and you continue to meet or exceed treatment goals If at any
point in treatment a Texas Health Choice Medical Director determines that treatment goals will not
be met the rehabilitative services will no longer be covered Treatment goals include recovery
restoration in function or improvement in the medical condition Treatment goals for a physically
disabled person as determined by a Texas Health Choice Medical Director may include
maintenance of functioning or prevention of or slowing of further deterioration
Diagnosis and treatment of infertility is covered you pay 10 per office visit The following types of artificial insemination are covered intracervical insemination ICI intravaginal insemination

IVI and intrauterine insemination IUI You pay 50 of charges The cost of donor sperm and
eggs are not covered Other assisted reproductive technology ART procedures such as in vitro
fertilization and gamete zygote intrafallopian transfers are not covered

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Texas Health Choice L C 2000
Section 5 BENEFITS continued
Limited benefits Drugs related to non covered infertility services are not covered Drugs used for covered infertility continued treatments are provided under the Prescription Drug Benefit at 50 of the charge to members who
do not have a prescription drug benefit
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is provided at a Plan facility for up to 36 sessions you pay 10 per visit

What is not Chiropractic services
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
External and internally implanted hearing aids
Homemaker services
Long term rehabilitative therapy
Transplants not listed as covered
Orthopedic devices such as braces and foot orthotics
Devices equipment supplies and prosthetics related to the treatment of sexual dysfunction
Any eye surgery solely for the purpose of correcting refractive defects in the eye such as nearsightedness myopia foresightedness hyperopia and stigmatism

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

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

Extended care The Plan provides a comprehensive range of benefits for up to 100 days per calendar year when full time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as
determined by 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 care and family counseling 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 You pay nothing Outpatient bereavement counseling
for each family member upon the death of a terminally ill member is covered for 5 group therapy visits or
a maximum of 500 per calendar year whichever is less You pay 10 per visit Respite care for each
family member of terminally ill members is covered up to 1,000 per calendar year for outpatient services
and 1,500 per calendar year for inpatient services You pay nothing for outpatient and inpatient
services

13 15
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Texas Health Choice L C 2000
Section 5 BENEFITS continued
Ambulance Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor You pay a
service 50 copay per trip

Limited benefits
Inpatient Dental Hospitalization for certain dental procedures is covered when a Plan doctor determines in conjunction
Procedures with a Texas Health Choice Medical Director that there is a need for hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the hospitalization but not the cost of the

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

Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis
detoxification treatment of medical conditions and medical management of withdrawal symptoms acute detoxification if the Plan doctor determines that outpatient management is not medically appropriate See page 16 for

non medical substance abuse benefits

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

Emergency
Benefits

What is a A medical emergency is the sudden and unexpected onset of a condition or an injury that you believe
medical endangers your life or could result in serious injury or disability and requires immediate medical or
emergency surgical care Some problems are emergencies because if not treated promptly they might become more serious examples include deep cuts and broken bones Others are emergencies because they are

potentially life threatening such as heart attacks strokes poisonings gunshot wounds or sudden
inability to breathe There are many other acute conditions that the Plan may determine are medical
emergencies what they all have in common is the need for quick action

Emergencies If you are in an emergency situation please call your primary care doctor In extreme emergencies if you
within the are unable to contact your doctor contact the local emergency system e g the 911 telephone system or
service area 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 the Plan must be notified within 48 hours or on the first working day
following your admission unless it was not reasonably possible to notify the Plan within that time If you
are hospitalized in non Plan facilities and Plan doctors believe care can be better provided in a Plan
hospital you 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

Plan pays Customary and reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers

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Texas Health Choice L C 2000
Section 5 BENEFITS continued
Emergency
within a service
area continued

You pay 50 per hospital emergency room visit waived if admitted as an inpatient or 25 per urgent care center
visit for emergency services that are covered benefits of this Plan 50 per ambulance trip copayments
as shown on page 18 for outpatient inpatient surgical procedures and outpatient surgical facility visits and
inpatient admissions 25 per non Plan doctor's office visit and all charges for services which are not a
covered benefit of this Plan

Emergencies Benefits are available for any medically necessary health service that is immediately required because of
outside the injury or unforeseen illness
service area If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day

following your admission unless it was not reasonably possible to notify the Plan within that time If a
Plan doctor believes care can be better provided in a Plan hospital you will be transferred when
medically feasible with any ambulance charges covered in full

To be covered by this Plan any follow up care recommended by non Plan providers must be approved by
the Plan or provided by Plan providers

Plan pays Reasonable charges for emergency care services to the extent the services would have been covered if received from Plan providers

You pay 50 per hospital emergency room visit waived if admitted as an inpatient or 25 per urgent care center visit for emergency services that are covered benefits of this Plan 50 per ambulance trip copayments
as shown on page 18 for outpatient inpatient surgical procedures and outpatient surgical facility visits and
inpatient admissions 25 per non Plan doctor's office visit and all charges for services which are not a
covered benefit of this Plan

What is covered Emergency care at a doctor's office or an urgent care center Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service approved by the Plan You pay 50 per ambulance trip

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

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

Filing claims for With your authorization the Plan will pay benefits directly to the providers of your emergency care upon
non plan receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form If you are
providers required to pay for the services submit itemized bills and your receipts to the Plan along with an explanation of the services and the identification information from your ID card Payment will be sent to

you or the provider if you did not pay the bill unless the claim is denied If it is denied you will receive
notice of the decision including the reasons for the denial and the provisions of the contract on which
denial was based If you disagree with the Plan's decision you may request reconsideration in
accordance with the disputed claims procedure described on page 14

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Texas Health Choice L C 2000
Section 5 BENEFITS continued
Mental
Conditions
Substance
Abuse Benefits

Mental
conditions

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

Diagnostic evaluation
Psychiatric treatment including individual and group therapy
Medical management visits including drug evaluation and maintenance You pay 10 per visit These visits are not charged as mental health outpatient visits

Hospitalization including inpatient professional services

Outpatient care Up to 40 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year You pay 10 per visit for group therapy and 20 for individual therapy for covered visits all charges
thereafter

Inpatient care Up to 30 days of hospitalization each calendar year You pay nothing per covered day of hospitalization all charges thereafter

What is not Care for psychiatric conditions which in the professional judgment of Plan doctors are not subject to
covered significant improvement through relatively short term treatment Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless

determined by a Plan doctor to be necessary and appropriate
Psychological testing except when needed as part of a medical evaluation

Serious Mental
Illness

What is covered Serious mental Coverage is provided for the medically necessary care diagnosis and treatment of serious mental illnesses Serious mental illness means the following psychiatric illnesses as defined by the
American Psychiatric Association in the Diagnostic and Statistical Manual DSM

schizophrenia
paranoid and other psychotic disorders
bipolar disorders hypomanic manic depressive and mixed
major depressive disorders single episode or recurrent
schizo affective disorders bipolar or depressive
pervasive developmental disorders and
obsessive compulsive disorders and
depression in childhood and adolescence

Outpatient care Up to 60 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year
You pay 10 for each covered visit all charges thereafter An outpatient visit for the purpose of
medication management does not count toward this 60 visit limit You pay 10 for each covered visit for
medication management

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Texas Health Choice L C 2000
Section 5 BENEFITS continued
Inpatient care Up to 45 days of inpatient treatment each calendar year You pay nothing
Substance
Abuse

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

Outpatient care Up to 40 outpatient visits to Plan providers for treatment each calendar year treatment for individual group and family counseling is covered to a maximum of 4 separate series of treatment per member you
pay a 10 copay for each covered visit all charges thereafter

Inpatient care Up to 30 days per calendar year in a substance abuse rehabilitation intermediate care program in an alcohol detoxification or rehabilitation center approved by the Plan you pay nothing during the benefit
period all charges thereafter

What is not Treatment that is not authorized by a Plan doctor
covered All charges if the member does not complete the substance abuse treatment program Substance abuse treatment on court ordered or as a condition of parole or probation unless

determined by a Texas Health Choice Medical Director to be to be necessary and appropriate

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 You pay a 6 copay per prescription unit or refill for generic
drugs and a 12 copay for brand name drugs when no generic equivalent is available
If you select a brand name drug when a generic equivalent is available and your doctor has not specified that only a brand name is sufficient you pay the amount by which the cost of the brand

name drug exceeds the cost of the generic equivalent in addition to the 6 copayment
Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary Non formulary drugs will be covered when prescribed by a Plan doctor You pay a 50 of charges

per prescription or refill
Mail Order A mail order program is available for up to a 90 day supply of covered maintenance medications for the
Pharmacy treatment of long term conditions such as diabetes arthritis heart disease and high blood pressure if
Option authorized by a Plan provider You pay two prescription copayments for up to a 90 day supply

Covered Infertility drugs You pay 50 of charges
medications and Drugs for which a prescription is required by law
accessories Insulin with a copay charge applied to each whole vial up to 40 ml
include Diabetic supplies including insulin syringes needles blood glucose measuring strips and urine checking reagents You pay nothing

Nitroglycerin phenobarbital or Thyroid U S P When prescribed in quantities of 100 a single copay charge will apply

Vitamins which require a prescription
Disposable needles and syringes needed to inject covered prescribed medication
Oral contraceptives

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Texas Health Choice L C 2000
Section 5 BENEFITS continued
Covered Contraceptive devices injectable and internally implanted time release medications except
medications and Norplant You pay the generic or brand name copay times the number of months the medication
accessories will be effective not to exceed 200
include continued Implanted contraceptive drugs such as Norplant are covered when other contraceptives are medically inappropriate or are contraindicated You pay 50 coinsurance for charges related to the device

implantation and removal There will be no refund of any portion of these copays if the implanted
time release medication is removed before the end of its expected life
Erectile dysfunction drugs You pay 50 of charges Dispensing limitations apply

Intravenous fluids and medication for home use implantable drugs and some injectable drugs are
covered under Medical and Surgical Benefits

What is not Smoking cessation drugs and medications
covered Drugs available without a prescription or for which there is a nonprescription equivalent available Drugs obtained at a non Plan pharmacy except for out of area emergencies

Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes
Drugs to enhance athletic performance

Other Benefits
Dental Care
What is covered The following dental services are covered when provided by participating Plan dentists You are limited to two visits per calendar year for any combination of the five preventive and diagnostic services listed
below You pay 10 per visit except where noted

Oral examinations you pay an additional 15 per emergency oral examination
Dental prophylaxis cleaning You pay and additional 10 per visit
Topical application of fluoride
Bitewing x rays no more than one set every six months
Full mouth series x rays as reasonable and necessary for dental diagnosis and treatment
Emergency dental services received outside the service area You pay an additional 25 per emergency visit

What is not Cosmetic dental services
covered Replacement of lost or stolen dentures appliances or bridgework Non emergency care received from non Plan dentist or non emergency care received outside of the

service area

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 prescriptions for eyeglasses may be obtained
from Plan providers You pay a 10 per visit

What is not Examinations for fitting of or prescriptions for contact lenses
covered Corrective eyeglasses and frames or contact lenses except as provided on page 18 under Benefits Eye exercises except for patients for whom amblyopia or strabismus is a concurrent diagnosis

18 20
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Texas Health Choice L C 2000
NON FEHBP BENEFITS AVAILABLE TO PLAN MEMBERS
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made
available to all enrollees and family members of this Plan The cost of the benefits described on this page is not included in the
FEHB premium and any charges for these services do not count toward any FEHB deductibles or out of pocket maximums These
benefits are not subject to the FEHB disputed claims procedure

Medicare If you are enrolled in this Plan through FEHBP have Medicare Part A coverage and have purchased Part
Prepaid Plan B coverage you may also enroll in the Texas Health Choice Golden Choice program
Enrollment The Golden Choice plan provides all Medicare covered Part A and Part B benefits to the Medicare

beneficiary as well as some benefits not covered by Medicare It is an arrangement between Medicare
and this Plan in which Medicare pays a specific amount to this plan for each Medicare beneficiary
who enrolls in the Plan

Like your FEHBP enrollment in this Plan you are required to obtain your services from this Plan's
doctors and providers except for emergencies and out of area urgent care The rules regarding
enrollment in Golden Choice are fully explained in the Plan's Evidence of Coverage For a copy of
these rules and or more information please contact Member Services at 1 800 466 8397

Following your enrollment in Golden Choice you will be entitled to receive an enhanced benefits
package that combines your FEHBP coverage with your Golden Choice benefits

If you choose to enroll in Golden Choice you will be responsible for paying the Medicare Part B
premium You must make an affirmative enrollment in Golden Choice Information regarding
enrollment and disenrollment rules may be found in the Evidence of Coverage for Golden Choice
Federal Members You will also continue to pay the employee share of the FEHBP premium

Health Our professional health educators dietitians exercise physiologists and registered nurses are
Education and committed to providing members with the tools necessary for lifelong wellness In addition to
Wellness preventive services such as pediatric immunizations flu shots and cholesterol screenings we provide a
Programs variety of health education programs Call 972 479 5155 or 972 263 2167 for class schedules and additional information

Vision Care
Services

Optical Fee Contact Lenses materials only 20 Discount
Schedule excludes disposable programmed replacement lenses fit and follow up professional services and prepaid service agreements

Real Value featuring everyday low package prices 10 Discount
Complete pair of glasses frames and lenses
Choose from selection of over 350 frames

Single vision starting at 109.00
Bifocal FT 28 starting at 89.00
Trifocal 7 x 28 starting at 119.00

Frames Lenses and Lens Options 33 Discount
Choose from over 2,000 frames including the latest in designer brands
Choose from the latest technology in lenses including thinner and lighter Hi index lenses and anti reflective coatings

Excludes package priced collection
19 21
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Texas Health Choice L C 2000
NON FEHBP BENEFITS AVAILABLE TO PLAN MEMBERS continued
Optical Fee Knockabouts No Rules Collection 15 Discount
Schedule continued Eye Care Centers of America policy is to provide eyewear for all school age children and young

adults that only include impact resistant polycarbonate lenses for maximum eye protection
Therefore all Knockabout frames are priced to include vision polycarbonate lenses
All Knockabout glasses have built in ultra violet protection scratch resistant coating and are guaranteed for one year against scratches and breakage

Choose from a selection of over 175 frames Featuring everyday low package prices starting at 87.00
Non Rx Sunglasses Accessories 20 Discount
Additional Items Not Listed Above 20 Discount
You must receive services from participating EyeMasters optical facilities listed in your provider
directory There is no premium charge for this benefit

Benefits on this page are not part of the FEHB contract

20 22
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Texas Health Choice L C 2000
Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it unless
your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition

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

Procedures services drugs 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 19

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

21 23
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Texas Health Choice L C 2000
Section 7 Limitations Rules that affect your benefits continued
Other group We will always provide you with the benefits described in this brochure Remember even if you do not
insurance file a claim with your other plan you must still tell us that you have double coverage
coverage continued

Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to provide
beyond our them In that case we will make all reasonable efforts to provide you with necessary care
control

When others are When you receive money to compensate you for medical or hospital care for injuries or illness that
responsible for another person caused you must reimburse us for whatever services we paid for We will cover the cost
injuries 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 We do not cover services that
compensation You need because of a workplace related disease or injury that the Office of Workers

Compensation Programs OWCP or a similar Federal or State agency determine they must provide
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws

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 or
Government indirectly pays for
Agencies

Section 8 FEHB FACTS
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the
information about right to information about your health plan its networks providers and facilities You can also
your HMO find out about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational

OPM's website www opm gov lists the specific types of information that we must make
available to you

If you want specific information about us call 1 800 466 8397 or write to Texas Health Choice
L C P O Box 15645 Las Vegas Nevada 89114 5645 You may also contact us by fax at 702
242 9350 or visit our website at www sierrahealth com

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Texas Health Choice L C 2000
Section 8 FEHB FACTS continued
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal
information Employees Health Benefits Plans brochures for other plans and other materials you need to make an
about enrolling informed decision about
in the 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 coverage and
benefits and premiums begin on the first day of your first pay period that starts on or after January 1 Annuitants
premiums premiums begin January 1
effective

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

described later in this section

What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and your
coverage are unmarried dependent children under age 22 including any foster or step children your employing or
available for me retirement office authorizes coverage for Under certain circumstances you may also get coverage for a
and my family disabled child 22 years of age or older who is incapable of self support

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

Your employing or retirement office will not notify you when a family member is no longer eligible to
receive health benefits nor will we Please tell us immediately when you add or remove family members
from your coverage for any reason including divorce

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

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

23 25
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Texas Health Choice L C 2000
Information for new members
Identification We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF2809
cards or the OPM annuitant confirmation letter until you receive your ID card You can also use an Employee Express confirmation letter

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

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

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

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

What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits under
spouse your spouse's enrollment But you may be eligible for your own FEHB coverage under the spouse
coverage equity law If you are recently divorced or are anticipating a divorce contact your ex spouse's employing or retirement office to get more information about your coverage choices

What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For example you can receive
TCC if you are not able to continue your FEHB enrollment after you retire You may not elect TCC if
you are fired from your Federal job due to gross misconduct

Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health
Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees from your
employing or retirement office

Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32 nd day after your regular coverage ends even if several months have passed

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

24 26
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Texas Health Choice L C 2000
When you lose benefits continued
How do I enroll If you are leave Federal service your employing office will notify you of your right to enroll under TCC
in 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 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 did not
coverage pay your premium you cannot convert You decided not to receive coverage under TCC or the spouse equity law or

You are not eligible for coverage under TCC or the spouse equity law

If you leave Federal service your employing office will notify you if individual coverage is available
You must apply in writing to us within 31 days after you receive this notice However if you are a family
member who is losing coverage the employing or retirement office will not notify you You must apply
in writing to us within 31 days after you are no longer eligible for coverage

Your benefits and rates will differ from those under the FEHB Program however you will not have to
answer questions about your health and we will not impose a waiting period or limit your coverage due
to pre existing conditions

How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage that
Certificate of indicates how long you have been enrolled with us You can use this certificate when getting health
Group Health insurance or other health care coverage You must arrange for the other coverage within 63 days of
Plan Coverage leaving this Plan Your new plan must reduce or eliminate waiting periods limitations or exclusions for health related conditions based on the information in the certificate

If you have been enrolled with us for less than 12 months but were previously enrolled in other FEHB
plans you may request a certificate from them as well

25 27
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Texas Health Choice L C 2000
Department of Defense FEHB Demonstration Project
What is the The National Defense Authorization Act for 1999 Public Law 105 261 established the DoD FHEHP
Department of Demonstration Project It allows some active and retired uniformed service members and their
Defense DoD dependents to enroll in the FEHB Program The demonstration will last for three years beginning with the
and FEHB 1999 Open Season for the year 2000 Open Season enrollments will be effective January 1 2000 DoD
Program and OPM have set up some special procedures to successfully implement the Demonstration Project
Demonstration noted below Otherwise the provisions described in this brochure apply
Project

Who is Eligible DoD determines who is eligible to enroll in FEHB Generally you may enroll if You are an active or retired uniformed service member and are eligible for Medicare

You are a dependent of an active or retired uniformed service member and are eligible for Medicare
You are a qualified former spouse of an active or retired uniformed service member and
You live in one of the eight geographic demonstration areas

If you are eligible to enroll in a plan under the regular Federal Employees Health Benefits Program you
are not eligible to enroll under the DoD FEHBP Demonstration Project

Where Are The Dover AFB DE
Demonstration Commonwealth of Puerto Rico
Areas Fort Knox KY Greensboro Winston Salem High Point NC

Dallas TX
Humboldt County CA area
Naval Hospital Camp Pendleton CA
New Orleans LA

When Can I Your first opportunity to enroll will be during the 1999 Open Season November 8 1999 through
Join December 13 1999 Your coverage will begin January 1 2000 DoD has set up Information Processing Center IPC in Iowa to provide you with information about how to enroll IPC staff will verify your

eligibility and provide you with FEHB Program information plan brochures enrollment instructions and
forms The toll free phone number for the IPC is 1 877 DOB FEHB 1 877 363 3342

You may select coverage for yourself self only or for you and your family self and family during
1999 2000 and 2001 Open Seasons Your coverage will begin January 1 of the year following the open
Season that you enrolled

If you become eligible for the DoD FEHBP Demonstration Project outside the Open Season contact the
IPC to find out how to enroll and when your coverage will begin

DoD has a web site devoted to the Demonstration Project You can view information such as their
Marketing Beneficiary Education Plan Frequently Asked Questions demonstration area locations and
zip code lists at www tricare osd mil fehbp You can also view information about the demonstration
project including The 2000 Guide to Federal Employees Health Benefits Plans Participating in the
DoD FEHBP Demonstration Project on the OPM web site at www opm gov

Am I eligible for See Section 10 FEHB Fact for information about TCC Under this Demonstration Project the only
Temporary eligible individual for TCC is one who ceases to be eligible as a member of family under your self and
Continuation of family enrollment This occurs when a child turns 22 for example or if you divorce and your spouse
Coverage does not qualify as an unremarried former spouse under title 10 United States Code For these
TCC individuals TCC begins the day after their enrollment to the DoD FEHBP Demonstration Project ends TCC enrollment terminates after 36 months or the end of the Demonstration Project whichever occurs

first You your child or another person must notify the IPC when a family member loses eligibility for
coverage under the DoD FEHBP Demonstration Project

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Texas Health Choice L C 2000
Department of Defense FEHB Demonstration Project continued
Am I eligible for TCC is not available if you move out of a DoD FEHBP Demonstration Project area you cancel your
Temporary coverage or your coverage is terminated for any reason TCC is not available when the demonstration
Continuation of project ends
Coverage
TCC continued

Do I have the These provisions do not apply to the DoD FEHBP Demonstration Project
31 Day
Extension and
Right To
Convert

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29 Page 30 31
Texas Health Choice L C 2000
Inspector General Advisory Stop Health Care Fraud

Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for
services you did not receive billed you twice for the same service or misrepresented any information do the following

Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 1 800 466 8397 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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Texas Health Choice L C 2000
Summary of Benefits for Texas Health Choice L C 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 13

Extended All necessary services up to 100 days each calendar year You pay nothing 13
Care

Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care
Conditions per calendar year You pay nothing 16

Serious Treatment for serious mental illness is provided for up to 45 days per calendar year You pay
Mental Illness nothing 17

Substance Treatment for substance abuse in a chemical dependency treatment center Treatment for
Abuse medical aspects and detoxification provided under hospital benefits You pay nothing for 30
inpatient days per calendar year 17

Outpatient Care Comprehensive range of services such as diagnosis and treatment of illness or injury including specialist's care preventive care including well baby care periodic check ups and
routine immunizations laboratory tests and x rays complete maternity care You pay 10 per
office visit You pay nothing for laboratory and x rays childhood immunizations prenatal
and postnatal office visits and nothing per house call by doctor

Home Health All necessary visits by nurses and health aids You pay nothing 12
Care

Mental Up to 40 visits per calendar year You pay 10 per visit 16
Conditions

Serious Treatment for serious mental illness is provided for up to 60 outpatient visits per calendar
Mental year You pay 10 16
Illness

Substance Treatment for substance abuse in a chemical dependency treatment center Treatment for
Abuse medical aspects and detoxification provided under hospital benefits No dollar or day limit
You pay 10 for each covered visit 17

Emergency Care Reasonable charges for services and supplies required because of a medical emergency You pay 100 for an emergency room visit waived if admitted to a hospital for each emergency
visit to a non Plan provider and copays other than office visit copays which would have
been paid to the Plan and any charges for services that are not covered benefits of this
Plan 14 15

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Texas Health Choice L C 2000
Summary of Benefits for Texas Health Choice L C 2000 continued
Prescription Drugs prescribed by a Plan doctor or participating dentist and obtained at a Plan pharmacy or
Drugs through mail order services You pay copays for formulary drugs and a coinsurance for nonformulary drugs 17 18

Dental Care Preventive and diagnostic services You pay copays for these services 18
Vision Care One refraction annually including eyeglass lens prescription You pay 10 per visit 18
Out of Pocket Copayments are required for a few benefits however after your out of pocket expenses
Limit reach a maximum of 600 per Self Only or 1,200 per Self and Family enrollment per calendar year covered benefits will be provided at 100 This copay maximum does not

include prescription drugs inpatient mental conditions benefits dental services durable
medical equipment benefit's or orthopedic and prosthetic device benefits 3

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Texas Health Choice L C 2000
2000 Rate Information for
TEXAS HEALTH CHOICE

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

Houston Beaumont areas
Self Only 2T1 51.44 17.14 111.44 37.15 60.86 7.72 60.86 7.72
Self and Family 2T2 131.66 43.89 285.27 95.09 155.80 19.75 155.80 19.75

Dallas Ft Worth areas
Self Only UK1 60.90 20.30 131.95 43.98 72.07 9.13 72.07 9.13
Self and Family UK2 155.88 51.96 337.74 112.58 184.46 23.38 184.46 23.38

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