Pages 1--28 from Untitled

Kaiser Permanente to be acquired by Capital District Physicians Health Plan Inc
2000

A Health Maintenance Organization

For changes benefits in
page 4 see

Serving Westchester County New York
Enrollment in this Plan is limited see page 5 for requirements
Enrollment code QH1 Self Only

QH2 Self and Family
Westchester County New York
The NCQA accreditation status for this service area is rated Commendable See the FEHB Guide for more information on NCQA

Special notice The Plan has eliminated a portion of its service area for 2000 If you are enrolled in this
Plan under enrollment code K1 and live in one of the following areas you must select another plan during
the Open Season to continue to receive full benefits Southwestern New Hampshire and Massachusetts

Visit the OPM website at http www opm gov insure and
the Kaiser Permanente website at http www kaiserpermanente org

Authorized for distribution by the
United States Office of Personnel Management
retirement and insurance service

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Kaiser Permanente 2000
Table of Contents

Introduction 2
Plain language 2
How to use this brochure 3
Section 1 Health Maintenance Organizations 4
Section 2 How we change for 2000 4
Section 3 How to get benefits 5
Section 4 What to do if we deny your claim or request for service 7
Section 5 Benefits 9
Section 6 General exclusions Things we don't cover 17
Section 7 Limitations Rules that affect your benefits 18
Section 8 FEHB FACTS 19
Inspector General Advisory Stop Healthcare Fraud 23
Summary of benefits Inside back cover
Premiums Back cover

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Kaiser Permanente 2000
Introduction

Kaiser Permanente 1 CHP Plaza
Latham NY 12110
This brochure describes the benefits you can receive from Kaiser Permanente to be acquired by Capital District Physicians Health Plan Inc CDPHP under its contract CS 1896 with the Office of Personnel Management OPM as authorized by the Federal
Employees Health Benefits FEHB law This brochure is the official statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this brochure If you are enrolled for Self and Family coverage each eligible
family member is also entitled to these benefits
OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on page 4 Premiums are listed at the end of this brochure

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

We refer to Kaiser Permanente to be acquired by CDPHP 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

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Kaiser Permanente 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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Kaiser Permanente 2000
Section 1 Health Maintenance Organizations

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

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

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

This year you have a right to more information about this Plan care management our networks facilities and providers
If you have a chronic or disabling condition and your provider leaves the Plan at our request you may continue to see your specialist for up to 90 days If your provider leaves the Plan and
you are in the second or third trimester of pregnancy you may be able to continue seeing your OB GYN until the end of your postpartum care You have similar rights if this Plan leaves the
FEHB program See Section 3 How to get benefits for more information
You may review and obtain copies of your medical records on request If you want copies of your medical records ask your health care provider for them You may ask that a physician
amend a record that is not accurate not relevant or incomplete If the physician does not amend your record you may add a brief statement to it If they do not provide you your
records call us and we will assist you
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years This screening is for colorectal cancer

Changes to this Plan Your share of the non postal premium will increase by 167.6 for Self Only or 198.3 for Self and Family
Hearing aids are no longer covered See page 11
The copayment for prescription drugs will change to 5 for generic prescriptions and 10 for brand name prescriptions unless another charge is specifically identified See page 15

Kaiser Permanente to be acquired by Capital District Physicians Health Plan Inc CDPHP This change does not effect benefits or rates
Services from other Kaiser Permanente Plans and benefits available while you travel for follow up care and continuing care are no longer available because this Plan will no longer
be affiliated with Kaiser Permanente

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Kaiser Permanente 2000
Section 3 How to get benefits

What is this Plan's To enroll in this Plan you must live or work in our service area This is where our providers service area practice Our service area is

Westchester County New York
Ordinarily you must receive your care from physicians hospitals and other providers who contract with us We also pay for emergency care obtained from any non Plan provider as
described on page 13 We will not pay for any other health care services
If you or a covered family member move outside of our service area you can enroll in another plan If your dependents live permanently outside of the area you should consider enrolling in
another plan If you or a family member move you do not have to wait until Open Season to change plans Contact your employing or retirement office

How much do I pay You must share the cost of some services This is called either a copayment a set dollar for services amount or coinsurance a set percentage of charges Please remember you must pay this
amount when you receive services If you do not pay at the time you receive your service you will be billed for the service We also will bill you an additional 10 This charge will be added
to each service for which you did not pay
Your out of pocket expenses for benefits under this Plan are limited to the stated copays required for a few benefits

Be sure to keep accurate records of your copayments and coinsurance since you are responsible for informing us when you reach the limits
Do I have to You normally won't have to submit claims to us unless you receive emergency services from a submit claims provider who doesn't contract with us If you file a claim please send us all of the documents
we need to respond to your claim as soon as possible You must submit claims by December 31 of the year after the year you received the service Either OPM or we can extend this deadline
if you show that circumstances beyond your control prevented you from filing on time
Who provides my This Plan offers comprehensive health care through a group of medical providers and affiliated health care specialists Plan physicians These medical offices are where your physician and his or her
support services are located Plan physicians arrange any necessary specialty care Other services such as physical therapy and laboratory and X ray are available at Plan facilities and
other designated locations Hospital care is provided through the Plan at several community hospitals

You must receive your health care services at Plan facilities except if you have an emergency
Your primary care physician PCP either a family practitioner pediatrician or internist will coordinate most aspects of your health care including arranging for you to receive services from
a specialist This Plan will cover specialists services only when your primary care physician refers you However a woman may see her gynecologist without having to obtain a referral

Choose your primary care physician at the medical office or an affiliated practice most convenient for you Use this Plan's provider directory in making your choice The directory which is
updated on a regular basis lists the physicians addresses phone numbers and lets you know whether the physician is accepting new patients To get a directory call the Member Relations
Department at 800 305 1992 in New York If you want to receive care from a specific physician who is listed in the directory call the physician to verify that he or she still participates
with the Plan and is accepting new patients
Notify the Plan of the primary care physician you choose Ask the Plan for a PCP selection form then complete and return it to the Plan If you need help choosing a primary care
physician call the Plan You may change your primary care physician or your health center by notifying the Plan The change is effective 30 days after we receive your notice

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Kaiser Permanente 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 Your primary care physician or specialist will make the necessary arrangements and continue to I need to go in to supervise your care
the hospital

What do I do if I'm First call the Member Relations Department at 800 305 1992 If you are new to the FEHB in the hospital when Program we will arrange for you to receive care If you are currently in the FEHB Program
I join this Plan and are switching to us your former plan will pay for the hospital stay until
You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized

How do I get Your primary care physician will determine if you need care from a specialist He or she will specialty care obtain necessary authorizations from the Plan The referral will describe the services you will
receive You should return to your primary care physician after your consultation with the specialist If your specialist recommends additional visits or services your primary care
physician will review the recommendation and authorize the visits or services as appropriate You should not go to a specialist unless your primary care physician and your Plan has
authorized the referral
If you need to see a specialist frequently because of a chronic complex or serious medical condition your primary care physician will develop a treatment plan that allows you to see
your specialist for a specified number of visits You will not need to obtain additional referrals Your primary care physician will obtain Plan authorization for these visits

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

What do I do if my Call your primary care physician who will arrange for you to see another specialist You may specialist leaves receive services from your current specialist until we can make arrangements for you to see

the Plan someone else

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

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

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Kaiser Permanente 2000
Section 3 How to get benefits continued

How do you Your physician must get our approval before sending you to a hospital referring you to a specialist authorize medical or recommending follow up care Before giving approval we consider if the service is
services medically necessary to prevent diagnose or treat an illness or condition We follow generally accepted medical practice in providing services to you

How do you decide When the service or supply including a drug 1 has not been approved by the FDA or 2 it if a service is is the subject of a new drug or new device application on file with the FDA or 3 is part of a
experimental or Phase I or Phase II clinical trial as the experimental or research arm of a Phase III clinical trial investigational or is intended to evaluate the safety toxicity or efficacy of the service or 4 is available as the
result of a written protocol that evaluates the service's safety toxicity or efficacy or 5 is subject to the approval or review of an Institutional Review Board or 6 requires an informed

consent that describes the service as experimental or investigational then this Plan considers that service supply or drug to be experimental and not covered by the Plan This Plan and its
Medical Group carefully evaluate whether a particular therapy is safe and effective or offers a degree of promise with respect to improving health outcomes The primary source of evidence
about health outcomes of any intervention is peer reviewed medical literature

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
When may I ask You may ask OPM to review the denial after you ask us to reconsider our initial denial or OPM to review refusal OPM will determine if we correctly applied the terms of our contract when we denied
a denial your claim or request for service
What if I have a Call us at 800 305 1992 and we will expedite our review serious or life
threatening condition and you haven't
responded to my request for service

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Kaiser Permanente 2000
Section 4 What to do if we deny your claim or request for service continued

What if you have If we expedite your review due to a serious medical condition and deny your claim we will denied my request inform OPM so that they can give your claim expedited treatment too Alternatively you can
for care and my call OPM's health benefits Division 3 at 202 606 0755 between 8 a m and 5 p m Serious or condition is serious life threatening conditions are ones that may cause permanent loss of bodily functions or death
or life threatening 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
What do I send Your request must be complete or OPM will return it to you You must send the following to OPM information

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

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

Who can make Those who have a legal right to file a disputed claim with OPM are the request
1 Anyone enrolled in the Plan
2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled person's representative They must send a copy of the person's specific written consent with

the review request
Where should I Send your request for review to Office of Personnel Management Office of Insurance mail my disputed Programs Contracts Division 3 P O Box 436 Washington D C 20044

claim to
What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our upholds the Plan's 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 Federal law governs your lawsuit benefits and payment of benefits The Federal court will if I file a lawsuit base its review on the record that was before OPM when OPM made its decision on your
claim You may recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment services supplies or drugs covered by us until you have completed the OPM review procedure
described above

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Kaiser Permanente 2000
Section 4 What to do if we deny your claim or request for service continued

Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects 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

Section 5 Benefits
Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan physicians and other Plan providers This includes all necessary office and outpatient surgery
visits You pay 10 per visit but no additional copay for laboratory test and X rays Office visits for pre natal care and well baby care are provided at no charge Within the service area

house calls will be provided if in the judgement of the Plan physician such care is necessary and appropriate you pay nothing for a physician's house call or for home visits by physicians
nurses and health aides
The following services are included
Preventive care and periodic check ups
Mammograms are covered as follows for women age 35 through 39 one mammogram during these five years for women age 40 through 49 one mammogram every one or two

years for women age 50 through 64 one mammogram every year and for women age 65 and above one mammogram every two years In addition to routine screening mammograms
are covered when prescribed by the physician as medically necessary to diagnose or treat your illness

Routine immunizations and boosters
Consultations by specialists
Diagnostic procedures such as laboratory test and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a plan physician 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 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
One annual self referred gynecological examination to participating plan gynecologist All other examinations must be arranged or provided by your primary care physician

Voluntary sterilization and family planning services
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment such as allergy serum including antigen materials
Blood blood products and the administration of blood
The insertion of internal prosthetic devices such as pacemakers and artificial joints

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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Kaiser Permanente 2000
Section 5 Benefits continued

Cornea heart heart lung kidney liver lung single and double and simultaneous pancreaskidney transplants allogeneic donor bone marrow transplants autologous bone marrow
transplants autologous stem cell and peripheral stem cell support for the following conditions acute lymphocytic or non lymphocytic leukemia advanced Hodgkin's lymphoma
advanced non Hodgkin's lymphoma advanced neuroblastoma and testicular mediastinal retroperitoneal and ovarian germ cell tumors Additionally autologous bone marrow transplants
autologous stem and peripheral stem cell support and high dose chemotherapy for the following conditions breast cancer multiple myeloma and epithelial ovarian cancer Related
medical and hospital expenses of the donor are covered
Women who undergo mastectomies may at their option have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure

Dialysis
Chemotherapy radiation therapy and respiratory therapy
Surgical treatment of morbid obesity
For homebound members residing in the service area home health services of physicians nurses and health aides when prescribed and directed by your Plan physician who will

periodically review the program for continuing appropriateness and need
Hearing tests
All necessary medical or surgical care in a hospital or extended care facility from Plan physicians and other Plan providers at no additional cost to you

Office visits and related diagnostic tests in connection with a second medical opinion concerning a positive or negative diagnosis of cancer or a recurrence of cancer or any recommendation
of a course of treatment for cancer The specialist rendering the second medical opinion must be a Kaiser Permanente affiliated specialist to whom the member received a
referral from a Plan primary care physician unless the member receives an approved referral to a non participating specialist from a Plan primary care physician Any further care rendered
beyond or as a result of the second opinion must be arranged by Plan physicians
If you do not pay any of the charges required for services at the time you receive the services you will be billed for those charges You will also be required to pay an administrative charge

of 10 for each service for which a bill is sent
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 treatment of radicular residual and follicular
cysts 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 that has resulted in 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 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

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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Kaiser Permanente 2000
Section 5 Benefits continued

Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis for up to two months per condition if significant improvement
can be expected within two months You pay nothing for inpatient care and 10 per outpatient session Rehabilitation is provided on an inpatient basis as part of a specialized multidisciplinary
therapy program in a specialized facility for up to two months per condition when in the judgment of the Plan physician significant improvement can be expected within two months
You pay nothing This benefit is reduced by any covered inpatient rehabilitation days in a skilled nursing facility Speech therapy is limited to treatment to restore normal speech
Occupational therapy is limited to services that assist the member to achieve self care and improved functioning in other activities of daily living

Diagnosis and treatment of infertility is covered You pay 10 per visit The following types of artificial insemination are covered intravaginal insemination IVI intracervical insemination
ICI and intrauterine insemination IUI You pay 10 per office visit Other assisted reproductive technology ART procedures such as in vitro fertilization gamete and zygote
intrafallopian transfers and embryo transfers are not covered Infertility services are not available when either member of the family has been voluntarily surgically sterilized Drugs related
to non covered infertility treatments are not covered
Cardiac rehabilitation following a heart bypass surgery or a myocardial infarction You pay 20

Orthopedic devices prosthetic devices and durable medical equipment DME when intended to be used repeatedly and in the home are covered You pay nothing for NortonBrown
back brace neck brace for fracture lenses following cataract removal and any brace for treatment of scoliosis For all other orthopedic and prosthetic devices and DME the Plan
pays a maximum of 1500 per member per year for any combination of these items This limit will not apply to breast protheses and surgical bras and their replacements Oxygen prescribed
by a Plan physician is covered You pay 20 of the charges not to exceed 3500 Foot orthotics are not covered The Plan will select the provider or vendor that will furnish covered
devices and DME DME coverage is limited to the standard item of DME in accord with the Plan's formulary guidelines that adequately meets the medical needs of the member The following
items are not covered under DME comfort and convenience equipment exercise and hygiene equipment disposable supplies electronic monitors of the function of the heart or
lungs except apnea monitors for newborns and devices to perform medical tests on blood or other bodily substances or excretions except blood glucose monitors for diabetics dental
appliances experimental or research equipment devices not medical in nature such as sauna baths and elevators modifications to the home or auto and chiropractic appliances

Chiropractic services defined as manual manipulation of the spine to correct nerve interference caused by distortion misalignment or subluxation of the vertebral column is covered All
other forms of chiropractic services are excluded
What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment insurance or governmental licensing or 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 and cognitive therapy
Transplants not listed as covered
Any eye surgery solely for the purpose of correcting refractive defects of the eye such as nearsightedness myopia farsightedness hyperopia and astigmatism

Special programs or clinics such as those for pain sports diet weight reduction acupuncture biofeedback hypnosis or massage

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Kaiser Permanente 2000
Section 5 Benefits continued

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 physician You pay nothing All necessary services are

covered including

Semiprivate room accommodations when a Plan physician determines it is medically necessary the physician may prescribe private accommodations or private duty nursing care

Specialized care units such as intensive care or cardiac care units
Prescribed drugs and their administration blood and blood products and the administration of blood biologicals supplies and equipment ordinarily provided or arranged as part of inpatient

services
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 physician You pay nothing All necessary services are covered including

Bed board and general nursing care
Prescribed drugs and their administration biologicals supplies and equipment ordinarily provided or arranged by the skilled nursing facility

Hospice care Supportive and palliative care for a terminally ill member is covered in the home You pay nothing Services include short term inpatient care limited to respite care and care for pain
control and acute and chronic symptom management outpatient care and family counseling these services are provided under the direction of a Plan physician who certifies that the patient

is in the terminal stages of illness with a life expectancy of six months or less Durable medical equipment is covered as part of this benefit

Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan physician You pay nothing
Limited benefits Inpatient dental Hospitalization for certain dental procedures is covered when a Plan physician 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 may 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 physician determines that outpatient management is not medically appropriate See page 15 for non medical substance abuse benefits

What is not covered Personal comfort items such as telephone and television
Custodial care and care in an intermediate care facility

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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Section 5 Benefits continued

Emergency Benefits
What is a medical A medical emergency is an injury or the sudden and unexpected onset of a condition or an emergency injury that you believe endangers your life or could result in serious injury or disability and
requires immediate medical or surgical care Some problems are emergencies because if not treated promptly they might become more serious examples include deep cuts and broken
bones Others are emergencies because they are potentially life threatening such as heart attacks strokes poisonings gunshot wounds or sudden inability to breathe There are many
other acute conditions that the Plan may determine are medical emergencies what they all have in common is the need for quick action

Emergencies within If you are in an emergency situation call your primary care physician directly the service area
In extreme emergencies if you are unable to contact your physician contact the local emergency system e g the 911 telephone system or go to the nearest hospital emergency room Be sure
to tell the emergency room personnel that you are a Plan member so they can notify the Plan You or a family member must notify the Plan within 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 physicians 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 Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 25 per visit to a hospital or urgent care center for emergency care services that are covered
benefits of this Plan If the emergency results in admission to a hospital you pay nothing

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

If you need to be hospitalized the Plan must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to notify the Plan within
that time If a Plan physician 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 services to the extent the services would have been covered if received from Plan providers
You pay 25 per visit to a hospital or urgent care center for emergency care services that are covered benefits of this Plan
What is covered Emergency care at a physician's office or an urgent care center
Emergency care as an outpatient or inpatient at a hospital including physicians services
Ambulance service approved by the Plan

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Section 5 Benefits continued

What is not covered Elective care or nonemergency care except as specified in Benefits Available Away From Home
Emergency or 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 non Plan providers care upon receipt of their claims Physician claims should be submitted on the HCFA 1500
claim form Submit claims to Kaiser Permanente Claims Department P O Box 15109 Albany New York 12212 5109 If you are required to pay for the services submit itemized bills and
your receipts to the Plan along with an explanation of the services and the identification information from your ID card

Payment will be sent to you or the provider if you did not pay the bill unless the claim is denied If it is denied you will receive notice of the decision including the reasons for the
denial and the provisions of the contract on which denial was based If you disagree with the Plan's decision you may request reconsideration in accordance with the disputed claims procedure
described on page 7
Mental Conditions Substance Abuse Benefits
Mental Conditions What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis

and treatment of acute psychiatric conditions including the treatment of mental illness or disorders
Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Medical management visits including drug evaluation and maintenance You pay 5 per visit These visits are not charged as mental health outpatient visits

Hospitalization including inpatient professional services
Outpatient care Up to 30 outpatient visits to Plan mental health providers each twelve month period a new twelve month period begins after twelve months have elapsed since your first visit You pay

5 per visit for each covered visit Unless an appointment is canceled at least 24 hours in advance the member must pay a charge of 25 for the broken appointment

Inpatient care Up to 60 days of hospitalization each calendar year You pay nothing for the first 60 days and all charges thereafter
Day and night care If in the professional judgment of a Plan physician a member would benefit from day care or night care services up to 120 sessions of such prescribed care are provided without charge each
calendar year However the number of such sessions is reduced by two sessions for each day of hospitalization for inpatient Mental Conditions services received during the calendar year Day
and night care sessions of no less than four and no more than 12 hour duration are provided in a hospital based or residential program Such care includes all services of Plan physicians and
mental health professionals In addition the following services and supplies as prescribed by a Plan physician are covered room and board psychiatric nursing care group therapy drugs and
medical supplies
If you do not pay any of the charges required for services at the time you receive the services you will be billed for those charges You will also be required to pay an administrative charge
of 10 for each service for which a bill is sent

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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Kaiser Permanente 2000
Section 5 Benefits continued
What is not covered Care for psychiatric conditions that in the professional judgment of Plan physicians are not subject to significant improvement through relatively short term treatment

Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless determined by a Plan physician to be necessary and appropriate
Psychological testing that is not medically necessary to determine the appropriate treatment of a short term psychiatric condition
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 In addition the Plan provides

Outpatient care Up to 60 outpatient visits to Plan providers in each twelve month period for treatment You pay 5 per visit for each covered visit Unless an appointment is canceled at least 24 hours in
advance the member must pay a charge of 25 for the broken appointment
Inpatient care Up to 30 days per calendar year for substance abuse rehabilitation intermediate care programs in a substance abuse detoxification or rehabilitation center approved by the Plan You pay
nothing during the benefit period and all charges thereafter
Day and night care If in the professional judgment of a Plan physician a member would benefit from day care or night care services up to 60 sessions of such prescribed care are provided without charge each
calendar year However the number of such sessions is reduced by two sessions for each day of hospitalization for Substance Abuse services received during the calendar Day care and
night care sessions of no less than six and no more than 12 hours duration are provided Such care includes all services of Plan physicians and mental health professionals In addition the
following services and supplies as prescribed by a Plan physician are covered room and board psychiatric nursing care group therapy drugs and medical supplies

What is not covered Treatment which is not authorized by a Plan physician
Substance abuse treatment on court order or as a condition of parole or probation unless determined by a Plan physician to be necessary and appropriate

Prescription Drug Benefits
What is covered Prescription drugs prescribed by Plan physicians or dentists and obtained at a Plan pharmacy will be dispensed for up to a 30 day supply If you choose a physician in one of our health
centers as your primary care physician prescriptions must be filled at a health center pharmacy If you choose an affiliated physician group physician as your primary care physician prescriptions
can be filled at either an affiliated network pharmacy or a health center pharmacy You pay 5 per generic or 10 per brand name prescription or refill It may be possible for you to
receive refills by mail at no extra charge Delivery may be made available at an additional charge Ask for details at a Plan pharmacy

This Plan uses a formulary to determine which prescribed drugs will be provided to members If the physician specifically prescribes a nonformulary drug because it is medically necessary
the nonformulary drug will be covered If you request the nonformulary drug when your physician has prescribed a substitution the nonformulary drug is not covered However you may
purchase the nonformulary drug from a Plan pharmacy at prices charged to members for noncovered drugs

The following drugs are drugs provided at the 5 charge for each generic prescription or a 10 charge for each brand name prescription unless another charge is specifically identified
Drugs for which a prescription is required by law
Oral contraceptive drugs and contraceptive diaphragms

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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Kaiser Permanente 2000
Section 5 Benefits continued

Implanted time release drugs and injectable contraceptives For Norplant you pay a one time 200 per prescription charge For Depo Provera you pay 15 For all other internally implanted
time release drugs and injectable contraceptives you pay a one time payment equal to 5 per prescription times the expected number of months the drug will be effective not to exceed
200 There will be no refund of any portion of these payments if the drug is removed before the end of its expected life

Insulin
Glucose test strips
Smoking cessation drugs Coverage is limited to one course of treatment per calendar year under the following conditions

1 the drug is prescribed by a Plan physician and 2 the member enrolls in a Plan approved behavioral intervention program

Injectable drugs for covered infertility treatments
Medically necessary enteral formulas proven to be effective as a disease specific treatment for individuals who are or will become malnourished or suffer from disorders which if untreated

will cause disability retardation or death
Modified solid food products for the treatment of certain inherited diseases of amino acid or organic acid metabolism up to a maximum of 2500 per person per calendar year

If you do not pay any of the charges required for services at the time you receive the services you will be billed for those charges You will also be required to pay an administrative charge
of 10 for each service for which a bill is sent
The Plan provides the following drugs at no charge
Any equipment necessary to use a prescribed drug
Disposable needles and syringes needed for injecting covered prescribed medication
Intravenous fluids and medication for home use
Limited Benefits Drugs to treat sexual dysfunction have dispensing limitations You pay 50 of charges Contact the Plan for details

What is not covered Drugs available without a prescription or for which there is a non prescription equivalent available
Drugs obtained at a non Plan pharmacy except 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
Drugs related to non covered infertility services

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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Kaiser Permanente 2000
Section 5 Benefits continued

Other Benefits
Dental care What is covered The following dental services are provided by participating Plan dentists You pay nothing

Bite wings and full mouth x rays when necessary
Instructions in plaque control twice per year
Basic prophylactic cleaning twice per year
Topical application of sealant and fluoride when necessary
Examination of teeth twice per year
Space maintainers when necessary
Scaling when necessary
Accidental injury Restorative services and supplies necessary to promptly repair but not replace sound natural benefit teeth are covered The need for these services must result from an accidental injury You pay

nothing All follow up care must be obtained from Plan dentists
What is not covered Other dental services not shown as covered
Dental implants
Vision care In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye this Plan provides certain vision care benefits from Plan providers

What is covered Eye refractions including lens prescriptions for eyeglasses You pay a 10 copay per refraction
Initial lenses following cataract surgery and lenses for keratoconus You pay nothing
What is not covered Corrective lenses except as noted above or frames including the fitting of the lenses
Eye exercises

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS

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 physician 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 doctors or hospitals except for authorized referrals or emergencies
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result

of an act of rape or incest
Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and

Expenses you incurred while you were not enrolled in this Plan
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Kaiser Permanente 2000
Section 7 Limitations Rules that affect your benefits

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

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

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

If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration SSA office or request it from SSA at 800 638 6833
Other group When anyone has coverage with us and with another group health plan it is called double insurance coverage coverage You must tell us if you or a family member has double coverage You must also send
us documents about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other plan is secondary it pays benefits next We decide which insurance is primary according to the
National Association of Insurance Commissioners Guidelines
If we pay second we will determine what the reasonable charge for the benefit should be After the first plan pays we will pay either what is left of the reasonable charge or our regular benefit
whichever is less We will not pay more than the reasonable charge If we are the secondary payer we may be entitled to receive payment from your primary plan

We will always provide you with the benefits described in this brochure Remember even if you do not file a claim with your other plan you must still tell us that you have double coverage
Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to beyond our control provide them In that case we will make all reasonable efforts to provide you with necessary
care

When others are When you receive money to compensate you for medical or hospital care for injuries or illness responsible for that another person caused you must reimburse us for whatever services we paid for We will
injuries cover the cost of treatment that exceeds the amount you received in the settlement If you do not seek damages you must agree to let us try This is called subrogation If you need more
information contact us for our subrogation procedures

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

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Kaiser Permanente 2000
Section 7 Limitations Rules that affect your benefits continued

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 Government We do not cover services and supplies that a local State or Federal Government agency directly Agencies or indirectly pays for

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

If you want specific information about us call 800 638 0668 or write to Kaiser Permanente 1 CHP Plaza Latham NY 12110 You may also contact us by fax at 518 785 2741 Or you can
visit our website at http kaiserpermanente org
Where do I get Your employing or retirement office can answer your questions and give you a Guide to information about Federal Employees Health Benefits Plans brochures for other plans and other materials you

enrolling in the need to make an informed decision about FEHB Program
When you may change your enrollment
How you can cover your family members
What happens when you transfer to another Federal agency go on leave without pay enter military service or retire

When your enrollment ends and
The next Open Season for enrollment

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

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

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Kaiser Permanente 2000
Section 8 FEHB FACTS continued

What happens when When you retire you can usually stay in the FEHB Program Generally you must have been 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 Self Only coverage is for you alone Self and Family coverage is for you your spouse and coverage are your unmarried dependent children under age 22 including any foster or stepchildren 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
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 and claims records access to it
confidential OPM this Plan and subcontractors when they administer this contract

This plan and appropriate third parties such as other insurance plans and the Office of Workers Compensation Programs OWCP when coordinating benefit payments and subrogating
claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions

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

OPM when reviewing a disputed claim or defending litigation about a claim
Information for new members
Identification cards We will send you an Identification ID card Use your copy of the Health Benefits Election Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card You
can also use an Employee Express confirmation letter
What if I paid a Your old plan's deductible continues until our coverage begins deductible under my

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

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Section 8 FEHB FACTS continued

When you lose benefits
What happens if my You will receive an additional 31 days of coverage for no additional premium when enrollment in this

Plan ends Your enrollment ends unless you cancel your enrollment or
You are a family member no longer eligible for coverage

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

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

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

Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees
from your employing or retirement office
Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32nd day after your regular coverage ends even if several months have passed

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

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Kaiser Permanente 2000
Section 8 FEHB FACTS continued

How do I enroll in If you are leave Federal service your employing office will notify you of your right to enroll TCC under TCC You must enroll within 60 days of leaving or receiving this notice whichever
is later
Children You must notify your employing or retirement office within 60 days after your child is no longer an eligible family member That office will send you information about enrolling
in TCC You must enroll your child within 60 days after they become eligible for TCC or receive this notice whichever is later

Former spouses You or your former spouse must notify your employing or retirement office within 60 days of one of these qualifying events
Divorce
Loss of spouse equity coverage within 36 months after the divorce

Your employing or retirement office will then send your former spouse information about enrolling in TCC Your former spouse must enroll within 60 days after the event which qualifies
them for coverage or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify your employing or retirement office within the 60 day deadline

How can I convert to You may convert to an individual policy if individual coverage
Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not pay your premium you cannot convert

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

If you leave Federal service your employing office will notify you if individual coverage is available You must apply in writing to us within 31 days after you receive this notice
However if you are a family member who is losing coverage the employing or retirement office will not notify you You must apply in writing to us within 31 days after you are no
longer eligible for coverage
Your benefits and rates will differ from those under the FEHB Program however you will not have to answer questions about your health and we will not impose a waiting period or limit
your coverage due to pre existing conditions
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage Certificate of that indicates how long you have been enrolled with us You can use this certificate when

Group Health Plan getting health insurance or other health care coverage You must arrange for the other 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

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Kaiser Permanente 2000
Inspector General Advisory Stop Health Care Fraud

Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for services you did not receive billed you twice for the same service or misrepresented any information do the following
Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 800 305 1990 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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Kaiser Permanente 2000
Notes

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Kaiser Permanente 2000
Summary of Benefits

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 AND FOLLOW UPAND CONTINUING CARE ARE COVERED ONLY WHEN PROVIDED OR ARRANGED BY PLAN PHYSICIANS

Benefits Plan pays provides Page
Inpatient care Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes in hospital physician 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 for up to 100 days per calendar year You pay nothing 12

Mental conditions Diagnosis and treatment of acute psychiatric conditions for up to 60 days of inpatient care per year You pay nothing 14
Substance abuse Up to 30 days per year in a substance abuse treatment program You pay nothing 15

Outpatient care Comprehensive range of services such as diagnosis and treatment of illness or injury including specialist's care preventive care periodic check ups and
routine immunizations laboratory tests and X rays complete maternity care
You pay 10 for office or outpatient surgery visit copays are waived for
maternity care and well baby visits nothing for a house call by a physician 9

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

Mental conditions Up to 30 outpatient visits per year You pay 5 per visit 14
Substance abuse Up to 60 outpatient visits per year You pay 5 per visit 15
Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay 25 and any charges for services that are not covered
benefits of this Plan 13
Prescription drugs Drugs prescribed by a Plan or referral physician and obtained at a Plan pharmacy You pay 5 per generic or 10 per brand name prescription or refill 15

Dental care Accidental injury benefit preventive dental care You pay nothing 17
Vision care One refraction annually including lens prescription You pay 10 per refraction initial lenses after cataract surgery You pay nothing 17

Out of pocket maximum Your out of pocket expenses for benefits under this Plan are limited to the stated copays required for a few benefits 5

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Kaiser Permanente 2000
2000 Rate Information for Kaiser Permanente

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

Self Only QH1 78.83 56.33 170.80 122.05 93.06 42.10 93.26 41.90
Self and Family QH2 175.97 153.26 381.27 332.06 207.74 121.49 201.02 128.21

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