Pages 1--28 from Untitled

For changes
to benefitssee page 3

Serving Northern and Southern California
Enrollment code
CY1 Self Only
CY2 Self and Family

See the FEHB Guide
for more information on NCQA

Enrollment in this Plan is limited see page 4 for requirements
Visit the OPM website at http www opm gov insure
and
this Plan's website at http www pacificare com

Authorized for distribution by the
UNITED
STATES

United States Office of Federal Employees OFFICE Personnel Management
Health Benefits Program OF

MANAGEMENT
Retirement and Insurance PERSONNEL RI 73 105 1
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PacifiCare of California 2000
Table of Contents

Introduction 1
Plain Language 1
How to use this brochure 2
Section 1 Health Maintenance Organizations 3
Section 2 How we change for 2000 3
Section 3 How to get benefits 4 5
Section 4 What to do if we deny your claim or request for service 6 7
Section 5 Benefits 7 15
Section 6 General Exclusions Things we don't cover 16
Section 7 Limitations Rules that affect your benefits 17 18
Section 8 FEHB FACTS 18 21
Department of Defense FEHB Demonstration Project 21 22
Inspector General Advisory Stop Healthcare Fraud 22
Summary of Benefits 25
Premiums 26

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PacifiCare of California 2000
Introduction
This Brochure describes the benefits you can receive from PacifiCare California Health Maintenance Organization HMO under its contract CS 1937 with the Office of Personnel Management OPM as authorized by the Federal Employees Heath Benefits

FEHB law This brochure is the official statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this brochure If you are enrolled for self and family coverage each eligible family member is also
entitled to these benefits
OPM negotiates benefits and premiums with each Plan annually Benefit changes are effective January 1 2000 and are shown on page 3 Premiums are listed at the end of this brochure

Plain Language
The President and Vice President are making the Government's communication more responsive accessible and understandable to the public by requiring agencies to use plain language Health Plan representatives and Office of Personnel Management staff have

worked cooperatively to make portions of this brochure clearer In it you will find common everyday words except for necessary technical terms you and other personal pronouns active voice and shorter sentences

We refer to PacifiCare California 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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PacifiCare of California 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 HMO's 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 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 information about the Federal Employees Health Benefits FEHB Program

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PacifiCare of California 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 listed in this brochure When you receive emergency services you may have to submit claim forms
You should join an HMO because you enjoy 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 copayment 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 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 Your share of the premium will increase by 4.1 for Self Only or will decrease by 0.3 for this Plan Self and Family
Woman may receive self referred gynecological care directly from a participating OB GYN or Family Practitioner within the selected primary medical group
The reconstructive surgery benefit now covers disfiguring congenital defects or developmental abnormalities for which surgical repair leads to improvement of the defect
and or appearance of the member Cardiac rehabilitation immediately following a heart transplant bypass surgery or a myocardial
infarction is provided with no day limit for a 10 copayment per visit Chiropractic services from a participating chiropractor are covered up to 20 visits per calendar
year for a 5 copayment per visit General anesthesia for certain dental procedures is covered for members under age 7 or
developmentally disabled The maintenance medication quantity is decreased to a 30 day supply for one copayment when
purchased at the pharmacy If you request a name brand drug you pay the 5 copayment plus the difference between the
cost of the brand name drug and the generic per prescription unit or refill Smoking cessation drugs and medication including nicotine patches are covered if the
member participates in the Stop Smoking program with a 20 copayment for 30 day supply Effective January 1 2000 the Plan will no longer provide service for the following counties
Amador Colusa Glenn Humbolt Lake Mendocino Monterey Nevada Sutter Tehama and Yuba

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PacifiCare of California 2000
Section 3 How to get benefits
What is this To enroll with us you must live or work in our service area This is where our providers practice Plan's service Our service area is
area The California counties of Alameda Butte Contra Costa Fresno Kern Kings Los Angeles
except Catalina Island Madera Marin Mariposa Merced Napa Orange Sacramento San Diego San Francisco San Joaquin San Mateo Santa Barbara Santa Clara Santa Cruz Solano
Sonoma Stanislaus Tulare Ventura Yolo and portions of the following counties as defined by zip codes

El Dorado 95613 95614 95619 95623 95633 36 95643 95651 95656 95664 95667 95672 95682 95684 95709 95726
Imperial 92227 92231 33 92243 44 92249 93350 92251 92257 92259 92273 92281
Placer 95602 04 95626 95631 95648 95650 95658 95661 95663 95668 95677 95678 95681 95703 95713 95717 95722 95736 95746 95747 95765

Riverside 91718 20 91752 91760 92201 03 92210 92211 92220 92223 92225 92226 92230 92234 36 92239 41 92253 55 92258 92260 64 92270 92272 92274 76 92282 92292
92302 03 92313 92320 92330 31 92343 92344 92348 92353 92355 92360 92362 92367 92369 92370 92379 92380 81 92383 92387 92388 92390 92395 92396 92500 99

San Bernardino 91701 91708 10 91729 30 91737 91739 91743 91758 59 91761 64 91784 91785 8I6 92252 92256 92277 92278 92284 92285 92286 92301 92305 92307 08 92310
18 92321 92322 92324 27 92329 92333 37 92339 42 92345 47 92350 92352 92354 92356 59 92365 92368 92369 92371 78 92382 92385 92386 92391 94 92397 99 92400 99

San Luis Obispo 90031 90032 93401 93412 93420 93424 93426 93428 93430 93432 93433 93435 93442 49 93451 53 93461 93465 93483

Ordinarily you must get your care from providers who contract with us If you receive care outside our service area we will pay only for emergency care We will not pay for any other health care
services
If you or a covered family member move outside of our service area you can enroll in another Plan If your dependent lives 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 You share the cost of some services This is called a copayment a set dollar amount or a I pay for coinsurance a set percentage of charges Please remember you must pay this amount when you
services receive services
After you pay 800 per self only or 2,400 per family you do not have to make any more 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 towards these limits and you must continue to make these payments

Be sure to keep accurate records of your copayments and coinsurance since you are responsible for informing us when you reach the limits
Do I have to 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 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 PacifiCare California is a mixed model Plan MMP This means the doctors provide care in my health contracted medical centers or in their own offices There are about 11,232 primary care physicians
care and 19,788 specialists participating in this Plan

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PacifiCare of California 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 I Talk to your Plan physician If you need to be hospitalized your primary care physician or need to go into the specialist will make the necessary arrangements and supervise your care
hospital
What do I do if First call our customer service department at 1 800 624 8822 If you are new to the FEHB I'm in the Program we will arrange for you to receive care If you are currently in the FEHB Program and are
hospital when switching to us your former plan will pay for the hospital stay until I 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 apply only to the person who is hospitalized
How do I get Your primary care physician will arrange your referral to a specialist except for OB GYN specialty care physician services which can be directly accessed on an unlimited basis without obtaining a
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 certain number of visits without additional referrals Your primary care physician will use our criteria when creating your treatment plan the physician may have to get an
authorization or approval beforehand

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

What do I do Call your primary care physician who will arrange for you to see another specialist You may if my specialist receive services from your current specialist until we can make arrangements for you to see
leaves the Plan someone else
Please contact us if you believe your condition is chronic or disabling You may able to continue seeing your provider for up to 90 days after we notify you that we are terminating the contract with
the provider unless the termination is for cause If you are in the second or third trimester of pregnancy you may continue to see your OB GYN until the end of your postpartum care

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

How do you Your 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 medically services necessary and if it follows generally accepted medical practice

How do you Our National and regional medical committees determine whether or not treatments procedures decide if a service and drugs are no longer considered experimental or investigational Our determinations are based
is experimental on the safety and efficacy of new medical procedures technologies devices and drugs or investigational

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PacifiCare of California 2000
Section 4 What to do if we deny your claim or request for service
If we deny your services or won't pay your claim you may ask us to reconsider our decision Your request must

1 Be in writing 2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were unable to make a timely request due to reasons beyond
your control
We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing 2 Pay the claim
3 Arrange for a health care provider to give you the service or 4 Ask for more information

If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30 days after we receive the additional information If we do not
receive the requested information within 60 days we will make our decision based on the information we already have

When may I You may ask OPM to review the denial after you ask us to reconsider our initial denial or refusal ask OPM to OPM will determine if we correctly applied the terms of our contract when we denied your claim
review a denial or request for service
What if I have Call us at 1 800 624 8822 and we will expedite our review a serious or
life threatening condition and you
haven't responded to my request for
service
What if you have If we expedite your review due to a serious medical condition and deny your claim we will inform denied my request OPM so that they can give your claim expedited treatment too Alternatively you can call OPM's
for care and my health benefits Contract Division IV at 202 606 0737 between 8 a m and 5 p m Serious or lifethreatening condition is serious conditions are ones that may cause permanent loss of bodily functions or death if they
or life threatening 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 our time limits initial denial or refusal of service You may also ask OPM to review your claim if

1 We did not answer your question 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
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PacifiCare of California 2000
Section 4 What to do if we deny your claim or request for service continued
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 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 Send your request for review to Office of Personnel Management Office of Insurance Programs I mail my Contracts Division IV 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 upholds the decision 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 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 base its if I file a lawsuit review on the record that was before OPM when OPM made its decision on your claim You may
recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment services supplies or drugs covered by us until you have completed the OPM review procedure
described above
Your records Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you and the and us to determine if our denial of your claim is correct The information OPM collects during the
Privacy Act review process becomes a permanent part of your disputed claims file and is subject to the provisions of the Freedom of Information Act and Privacy Act OPM may disclose this information

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

Section 5 Medical and Surgical Benefits
What is A comprehensive range of preventive diagnostic and treatment services is provided by Plan covered physicians and other Plan providers This includes all necessary office visits you pay a 10 office
visit copayment but no additional copayment for laboratory tests and X rays Within the service area house calls will be provided if in the judgment of the Plan physician such care is necessary
and appropriate you pay a 10 copayment for a physician's house call and no charge for home visits by nurses and health aides

The following services are included
Preventive care including well baby care and periodic check ups you pay nothing for well baby and child care from birth to age 2
Mammograms are covered as follows for women age 35 through age 39 one mammogram during these five years for women age 40 through 49 one mammogram every one or two
years for women age 50 through 64 one mammogram every year and for women age 65 and above one mammogram every two years In addition to routine screening mammograms are
covered when prescribed by the doctor as medically necessary to diagnose or treat your illness Immunizations and boosters as recommended by the American Academy of Pediatrics you
pay nothing for children birth to age 2 Consultations by specialists

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 7 9
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PacifiCare of California 2000
Section 5 Medical and Surgical Benefits continued
What is Complete obstetrical maternity care for all covered females including prenatal delivery and covered postnatal care by a Plan physician you pay nothing The mother at her option may remain in
continued the hospital up to 48 hours after a regular delivery and 96 hours after a cesarean delivery Inpatient stays will be extended if medically necessary If enrollment in the Plan is terminated
during pregnancy benefits will not be provided after coverage under the Plan has ended Ordinary nursery care of the newborn child during the covered portion of the 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 Self referred gynecological physician care provided by an OB GYN or Family Practitioner
within your selected primary medical group you pay a 10 copayment per exam Voluntary family planning services including injectable contraceptive drugs such as Depo
Provera and implantable contraceptive devices such as Norplant and IUD's Sterilization you pay a 50 copayment for a vasectomy you pay a 100 copayment 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
Heart cornea kidney heart lung liver lung single or double and pancreas transplants allogeneic donor bone marrow transplants autologous bone marrow transplants autologous
stem cell and peripheral stem cell support for the following conditions acute lymphocytic or non lymphocytic leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's
lymphoma advanced neuroblastoma breast cancer multiple myeloma epithelial ovarian cancer and testicular mediastinal retroperitoneal and ovarian germ cell tumors Related
medical and hospital expenses of the donor are covered when the recipient is covered by this Plan Bone Marrow searches are limited to 10,000 or fifty 50 potential donors whichever
occurs first Women who undergo mastectomies may at their option have this procedure performed on an
inpatient basis and remain in the hospital up to 48 hours after the procedure Dialysis
Chemotherapy radiation therapy and inhalation therapy Surgical treatment of morbid obesity
Orthopedic devices such as braces foot orthotics Prosthetic devices such as artificial limbs lenses following cataract removal and breast
prostheses and surgical bras as well as their replacement following a mastectomy Durable medical equipment such as wheelchairs and hospital beds
Home health services of nurses and health aides including intravenous fluids and medications when prescribed by your Plan physician 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
physicians and other Plan providers at no additional cost to you Disposable needles and syringes needed for injecting covered prescribed medication
Cardiac rehabilitation immediately following a heart transplant bypass surgery or a myocardial infarction

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 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 that has resulted in a functional defect or that has resulted from an injury or surgery that has produced a major effect on the
member's appearance and if the condition can reasonably be expected to be corrected by such surgery A patient and her attending physician may decide whether to have breast reconstruction
surgery following a mastectomy and whether surgery on the other breast is needed to produce a symmetrical appearance

8 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 10
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PacifiCare of California 2000
Section 5 Medical and Surgical Benefits continued
Limited benefits Short term rehabilitative therapy or sub acute care physical speech and occupational is continued provided on an inpatient or outpatient basis with no day limit when medically necessary you pay
10 per outpatient session Speech therapy is limited to treatment of certain speech impairments of organic origin Occupational therapy is limited to services that assist the member to achieve and
maintain self care and improved functioning in other activities of daily living
Diagnosis and treatment of infertility is covered including but not limited to sperm count hysterosalpingography endometrial biopsy or oral fertility drugs you pay 50 of charges Other
fertility drugs are not covered The following types of artificial insemination are covered intravaginal insemination IVI intracervical insemination ICI intrauterine insemination IUI
you pay 50 of charges cost of donor sperm is not covered Other assisted reproductive technology ART procedures such as in vitro fertilization and embryo transfer are not covered

Chiropractic services are available through American Specialty Health Plans ASHP and ChiroCare Sierra You will have direct access to a participating chiropractor without a referral from
a Primary Care Physician You pay a 5 copayment per visit up to 20 visits per calendar year
What is not Physical examinations that are not necessary for medical reasons such as those required for covered obtaining or continuing employment or insurance attending school or camp or travel
Reversal of voluntary surgically induced sterility Surgery primarily for cosmetic purposes
Hearing aids Homemaker services
Long term rehabilitative therapy Transplants not listed as covered

Section 5 Hospital Extended Care Benefits
What is covered

Hospital care The Plan arranges for 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 per inpatient admission 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 Blood and blood derivatives

Extended care The Plan arranges for a comprehensive range of benefits up to 100 consecutive days per disability per calendar year when full time skilled nursing or transitional care is necessary and confinement
in a skilled nursing facility is medically appropriate as determined by a Plan physician and approved by the Plan You pay nothing per inpatient admission 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 physician
Hospice care Supportive and palliative care for a terminally ill member is covered in the home or hospice facility
up to a 180 day limit per lifetime Services include inpatient and 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 approximately six months or less

Ambulance care Benefits are provided for ambulance transportation ordered or authorized by a Plan physician when utilized in an emergency or through the 911 emergency response system
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 9 11
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PacifiCare of California 2000
Section 5 Hospital Extended Care Benefits continued
Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan physician determines there is a procedures need for general anesthesia 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 unless the
member is under the age of 7 or developmentally disabled
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 12 for non medical Substance Abuse Benefits

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

Section 5 Emergency Benefits
What is a A medical emergency is the sudden and unexpected onset of a condition or an injury that you medical believe endangers your life or could result in serious injury or disability and requires immediate
emergency 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 In emergencies contact the local emergency system e g the 911 telephone system or go to the within the nearest hospital emergency room Be sure to tell the emergency room personnel that you are a Plan
service area member so they can notify the Plan You or a family member should notify your primary care physician within 48 hours unless it is not reasonably possible to do so It is your responsibility to
ensure that your primary care physician has been timely notified
If you need to be hospitalized your primary care physician should be notified within 24 hours or on the first working day following your admission unless it was not reasonably possible to notify
your primary care physician 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 35 per hospital emergency room visit or urgent care center visits for emergency services that are covered benefits of this Plan If the emergency results in admission to a hospital the emergency
care copayment is waived

10 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 12
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PacifiCare of California 2000
Section 5 Emergency Benefits continued
Emergencies Benefits are available for any medically necessary emergency health services or urgently needed outside the service that is immediately required because of injury or unforeseen illness
service area If you need to be hospitalized the Plan should be notified within 24 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 care services to the extent the services would have been covered if received from Plan providers
You pay 35 per hospital emergency room visit or urgent care center visit for emergency services which are covered benefits of this Plan If the emergency results in admission to a hospital the emergency
care copayment is waived
What is Emergency care at a physician's office or an urgent care center covered Emergency care as an outpatient or inpatient at a hospital including physician services
Ambulance services when member reasonably believes services are necessary
What is not Elective care or nonemergency 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 Routine follow up care

Filing claims With your authorization the Plan will pay benefits directly to the providers of your emergency care for non Plan upon receipt of their claims Physician claims should be submitted on the HCFA 1500 claim form
providers 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 6

Section 5 Mental Conditions Substance Abuse Benefits
Mental conditions
What is To the extent shown below this Plan arranges for the following services necessary for the diagnosis covered and treatment of acute psychiatric conditions including the treatment of mental illness or disorders

Care must be arranged in advance by the PacifiCare Behavioral Health Employee Assistance Program EAP by calling 1 800 234 5465

Diagnostic evaluation Psychological testing
Psychiatric treatment including individual and group therapy Hospitalization including inpatient professional services

Outpatient Up to 40 outpatient visits to Plan physicians consultants or other psychiatric personnel each care calendar year you pay nothing for visits 1 through 5 10 per visit for visits 6 10 15 per visit for
visits 11 20 and 20 per visit for visits 21 40
The first 20 visits must be authorized by calling PacifiCare Behavioral Health EAP at 1 800 234 5465 visits 21 40 must be authorized by your primary care physician The EAP will coordinate the

transition of care It is important to know that we cannot guarantee that the provider rendering care for the second 20 visits will be the same one that provided care during the first 20 visits

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 11 13
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PacifiCare of California 2000
Section 5 Mental Conditions Substance Abuse Benefits continued
Inpatient Up to 30 days of hospitalization each calendar year you pay nothing for the first 30 days all care charges thereafter All inpatient care must be pre authorized by calling PacifiCare Behavioral
Health EAP at 1 800 234 5465
What is not Care for psychiatric conditions that in the professional judgment of Plan physicians are not covered 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 when not medically necessary to determine the appropriate treatment of a short term psychiatric condition
Treatment for any learning developmental disability or reading disorder Counseling for adoption custody family planning or pregnancy in the absence of a psychiatric
diagnosis generally recognized and accepted by the medical community and limited to a DSMIV psychiatric diagnosis
Spiritual counseling dance poetry music or art therapy Certain organic and non organic therapies call PacifiCare Behavioral Health PBHI for
specifics Personal enhancement or wellness and development

Substance abuse
What is This Plan arranges for medical and hospital services such as acute detoxification services for the covered medical non psychiatric aspects of substance abuse including alcoholism and drug addiction the

same as for any other illness or condition Services for the psychiatric aspects are provided in conjunction with the mental condition benefits shown above Outpatient visits to Plan mental
health providers for follow up care and counseling are covered as well as inpatient services necessary for diagnosis and treatment The mental conditions benefits visit day limitations and
copayments apply to any covered substance abuse care
What is not Rehabilitative care in a specialized facility for substance abuse Treatment that is not authorized covered by a Plan physician

Section 5 Prescription Drug Benefits
What is Prescription drugs prescribed by a Plan or referral physician and obtained at a Plan pharmacy will covered be dispensed for up to a 30 day supply drugs are prescribed by Plan physicians and dispensed in
accordance with the Plan's drug formulary Non formulary drugs will be covered when prescribed by a Plan doctor

The PacifiCare formulary is a list of over 1600 prescription drugs that physicians use as a guide when prescribing medications for patients The formulary plays an important role in providing
safe effective and affordable prescription drugs to PacifiCare members It also allows us to work together with physicians and pharmacies to ensure that our members are getting the drug therapy
they need A Pharmacy and Therapeutics committee consisting of physicians and pharmacists evaluate prescription drugs based on safety effectiveness quality treatment and Overall value The
committee considers first and foremost the safety and effectiveness of a medication before reviewing the cost PacifiCare will not cover a non Formulary prescription recommended by a
participating physician unless the non Formulary drug is pre authorized A participating physician may initiate the pre authorization request simply by phoning or faxing in the request Requests are
generally processed within ten minutes Although a few require up to two working days when additional information is needed from the doctor

12 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 14
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PacifiCare of California 2000
Section 5 Prescription Drug Benefits continued
What is For drugs otherwise excluded from coverage pre authorization of non Formulary drugs will occur covered in the following instances
continued No Formulary alternative is appropriate
You have tried the Formulary drugs and they have not been effective or you have been experiencing side effects or interactions with other drugs The physician is asked to provide a
copy of the medical chart notes specifically stating treatment failure with the Formulary alternatives
You have been under treatment and remain stable on a non Formulary prescription drug and a conversion to a Formulary drug would be medically inappropriate
Your physician provides evidence to PacifiCare in the form of documents records or clinical trials which establishes that use of the requested non Formulary drug over the Formulary drug
is medically necessary as determined by PacifiCare
You pay a 5 copayment for generic and a 10 copayment for name brand drugs per prescription unit or refill on the formulary Maintenance medications may be dispensed for up to a 30 day
supply for the cost of one copayment
When generic substitution is permissible i e generic drug is available and the prescribing doctor does not require the use of the brand name drug but you request the brand name you may
purchase the brand name drug instead of the generic drug by paying your 5 copayment plus the difference between the cost of the brand name and the generic drug per prescription unit or refill

Up to a 90 day supply of maintenance medications may be obtained through mail order for the cost of two copayments For information on the mail order drug benefit contact the Plan's Member
Services Department at 1 800 624 8822
Covered medications and accessories include
Drugs for which a prescription is required by law Oral contraceptive drugs
Prescription diaphragms Insulin
Diabetic supplies limited to insulin syringes and blood test tape and lancets Intravenous fluids and medication for home use covered under Medical and Surgical Benefits
as a home health service see page 8 Prenatal vitamins
Inhaler extender devices anaphylaxis prevention kits including but not limited to epipen anakits and anagard
Smoking cessation drugs and medication including nicotine patches if the member participates in the Plan's Stop Smoking program You pay a 20 copayment for a 30 day supply

Limited benefits Drugs to treat sexual dysfunction are covered when Plan's medical criteria is met Contact the plan for dose limits You pay 50 of the cost of the medication per prescription unit or refill
up to the dosage limits and all charges above that
What is not Drugs available without a prescription or for which there is a non prescription equivalent covered available

Drugs obtained at a non Plan pharmacy except for an emergency Medical supplies such as dressings and antiseptics
Drugs for cosmetic purposes Drugs to enhance athletic performance
Fertility drugs except oral which are covered under Diagnosis and Treatment of Infertility page 9
Dietary supplements vitamins and fluoride supplements except prenatal Diet Pills
Lifestyle enhancing drugs

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 13 15
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PacifiCare of California 2000
Section 5 Other Benefits
Dental care
Accidental Oral surgical procedures will be provided in an outpatient or inpatient setting when approved by the injury Plan in connection with the following Stabilization and emergency treatment within forty eight

Benefit 48 hours of an acute accidental injury to sound natural teeth jaw bone or surrounding tissue The need for these services must result from an accidental injury You pay nothing

What is not Other dental services not shown as covered covered
Vision care
What is In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of covered the eye this Plan provides the following vision care benefits from Plan providers You pay a 10
copayment per visit
Annual eye refraction including the written lens prescription for eyeglasses
Initial placement of post cataract extraction contact lens in surgically affected eye
What is not Eye exercises covered Replacement of initial lens following cataract surgery
Eyewear contact lenses and contact lens exams

14 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 16
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PacifiCare of California 2000
Non FEHB Benefits Available to Plan Members The benefits described on this page are neither offered nor guaranteed under the contract with FEHB Program but are made available to all enrollees and family members of the Plan The cost of the benefits described on this page is not included in the FEHB premium any charges for
these services do not count toward any FEHB deductibles out of pocket maximum copay charges etc These benefits are not subject to the FEHB disputed claims procedures
PacifiCare 590 Dental Plan NEW Plan B Federal Dental Plan
This dental HMO plan offers limited copayments no Now available exclusively for PacifiCare of California health deductibles and no annual maximum except for specialty plan members This plan allows you to see any dentist in our

referral as long as you see a participating plan provider directory You are not assigned a primary dentist The
You can review this brief summary of benefits and following fees apply only if service is performed by a general copayments For a more detailed explanation of benefits dentist Fees in a specialist's office will be higher

please refer to the dental information enclosed in your member Member Pays material For more comprehensive information please call us Diagnostic Office visit 5
at PacifiCare Dental Vision at 1 800 228 3384 Diagnostic X rays single film 5
Member Pays Preventive Teeth cleaning two per 12 months 5
Diagnostic Office visit No Charge Restorative Dentistry Amalgam restorations Diagnostic X rays single film No Charge One tooth surface cavities involving primary and

Preventive Teeth cleaning two per 12 months No Charge permanent teeth 5 Restorative Dentistry Amalgam restorations Oral Surgery Extraction uncomplicated 72
One tooth surface cavities involving primary and Endodontics Root canals anterior bicuspid molar permanent teeth 4 309 422 490
Oral Surgery Extraction uncomplicated 10 Periodontics Gingival curettage surgical per quad 89 Endodontics Root canals anterior bicuspid molar Crowns and Pontics Porcelain fused to metal 524
80 100 140 Prosthetics Complete upper or lower denture 600 Periodontics Gingival curettage surgical per quad 40 Orthodontics Class I II or III 1,895
Crowns and Pontics Porcelain crown 120 not for molars plus actual lab cost of gold if applicable Prosthetics Complete upper or lower denture 175
Plan B Monthly Premium Orthodontics Class I II or III 1,895
not for molars plus actual lab cost of gold if applicable Single 3.06
Couple 7.91
PacifiCare Vision Eyewear Only Plan

Enjoy great savings on prescription eyewear Before you use How to Enroll the Eyewear Only Plan your eye exam must be obtained To Enroll complete the PacifiCare Dental Vision

through your medical plan Then select your eyewear Member Enrollment form note your selected 590 dental glasses or contacts If you choose eyewear from a provider
provider and pre authorized payment plan agreement on our directory and stay within the frame allowance you can Member Enrollment forms received by the 20th of the

obtain eyewear at virtually no cost If you choose eyewear month will become effective the 1st of the following more expensive frames or see a provider not on our list you
month will have to pay additional but discounted costs

Premiums This sheet lists only a summary of benefits and copayments For a more detailed explanation of benefits
Combined 590 Dental Vision Monthly Premium please refer to the dental and vision information enclosed Single 18.63
in your member material Couple 34.07

Family 51.97 For questions please call PacifiCare Dental and Vision's 590 Dental Only Monthly Premium
Member Service at 1 800 228 3384 Single 14.67

Couple 28.33 Visit our website at www pacificare com dentalvision Family 41.75
Vision Only Monthly Premium Single 4.75
Couple 9.50 Family 14.25

Medicare Prepaid Plan Enrollment This Plan offers Medicare recipients the opportunity to enroll in the Plan through Medicare As indicated on Page 17 annuitants and former spouses with FEHB coverage and Medicare Part B may elect to drop their FEHB coverage and enroll in a
Medicare prepaid plan when one is available in their area They may then later reenroll in the FEHB Program Most Federal annuitants have
Medicare Those without Medicare Part A may join this Medicare Prepaid Plan but will probably have to pay for hospital coverage in addition to the
Part B premium Before you join the Plan ask whether the Plan covers hospital benefits and if so what you will have to pay Contact your retirement
system for information on dropping your FEHB enrollment and changing to a Medicare prepaid plan Contact us at 1 800 322 8877 for information
on the Medicare prepaid plan and the cost of that enrollment

If you are Medicare eligible and are interested in enrolling in a Medicare HMO sponsored by this Plan without dropping your enrollment in this Plan's
FEHB plan call 1 800 322 8877 for information on the benefits available under the Medicare HMO

Benefits on this page are not part of the FEHB contract 068 R8 99

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PacifiCare of California 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 emergencies or urgently needed
care see Emergency Benefits or eligible self referred services 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 Expenses you incurred while you were not enrolled in this Plan

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PacifiCare of California 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 the medical services and we will coordinate the payments On
occasion you may need to file 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 reenroll 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 15
Other group When anyone has coverage with us and 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
coverage about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other plan is secondary it pays benefits next We decide which insurance is primary according to the
National Association of Insurance Commissioners Guidelines
If we pay second we will determine what the reasonable charge for the benefit should be After the first plan pays we will pay either what is left of the reasonable charge or our regular benefit
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 also provide you with the benefits described in this brochure Remember even if you do not file a claim with your other plan you must tell us that you have double coverage
Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to beyond our provide them In that case we will make all reasonable efforts to provide you with necessary care
control
When others When you receive money to compensate you for medical or hospital care for injuries or illness that are responsible another person caused you must reimburse us for whatever services we paid for We will cover the
for injuries cost of treatment that exceeds the amount you received in the settlement If you do not seek 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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PacifiCare of California 2000
Section 7 Limitations Rules that affect your benefits continued
Workers We do not cover services that compensation

You need because of work place 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 this Plan and Medicaid covers you
Other Government We do not cover services and supplies that a local State or Federal Government agency directly or Agencies indirectly pays for

If you have a malpractice claim
If you have a malpractice claim because of services you did or did not receive from a Plan provider it must go to binding arbitration Contact us about how to begin our binding arbitration process

Section 8 FEHB FACTS
You have a right OPM requires that all FEHB Plans comply with the Patients Bill of Rights which gives you the to information right to information about your health plan its networks providers and facilities You can also find

about your HMO 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 1 800 624 8822 or write to 5701 Katella Avenue Cypress CA 90630 You may also contact us by fax at 671 646 6923 or visit our website at
www pacificare com
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal information about Employees Health Benefits Plans brochures for other plans and other materials you need to make
enrolling in the 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 coverage benefits and and premiums begin on the first day of your first pay period that starts on or after January 1
premiums effective Annuitants premiums begin on January 1
What happens When you retire you can usually stay in the FEHB Program Generally you must have been when I retire enrolled in the FEHB Program for the last five years of your Federal service If you do not meet
this requirement you may be eligible for other forms of coverage such as Temporary Continuation of Coverage which is described later in this section

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PacifiCare of California 2000
Section 8 FEHB FACTS continued
What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and your coverage are unmarried dependant children under age 22 including any foster or step children your employing

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

If you have 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 access to it
records 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 a 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 809 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 conditions you enrolled in this Plan solely because you had the condition before you enrolled

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

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PacifiCare of California 2000
Section 8 FEHB FACTS continued
What is former If you divorced from a Federal employee or annuitant you may not continue to get benefits under spouse coverage 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 exspouse'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 Federal 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

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

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

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PacifiCare of California 2000
Section 8 FEHB FACTS continued
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 Group indicates how long you have been enrolled with us You can use this certificate when getting health
Health Plan insurance or other health care coverage You must arrange for the other coverage within 63 days of 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 this certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in the other FEHB plans you may request a certificate from them as well

Department of Defense FEHB Demonstration Project
What is the The National Defense Authorization Act for 1999 Public Law 105 261 established the Department DoD FEHBP Demonstration Project It allows some active and retired uniformed service members
of Defense and their dependents to enroll in the FEHB Program The demonstration will last for three years DoD and beginning with the 1999 Open Season for the year 2000 Open Season enrollments will be
FEHB Program effective January 1 2000 DoD and OPM have set up some special procedures to successfully Demonstration implement the Demonstration Project noted below Otherwise the provisions described in this
Project brochure apply
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
have not remarried or You are a survivor dependent of a deceased 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 join Your first opportunity to enroll will be during the 1999 Open Season November 8 1999 through December 13 1999 Your coverage will begin January 1 2000 DoD has set up an 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 DOD FEHB 1 877 363 3342

You may select coverage for yourself self only or for you and your family self and family during the 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 of Open Season contact the IPC to find out how to enroll and when your coverage will begin

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PacifiCare of California 2000
Department of Defense FEHB Demonstration Project continued
When can I join DoD has a web site devoted to the Demonstration Project You can view information such as their continued 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 See Section 10 FEHB Facts for information about TCC Under this Demonstration Project the for Temporary only individual eligible for TCC is one who ceases to be eligible as a member of family under
Continuation of your self and family enrollment This occurs when a child turns 22 for example or if you divorce Coverage TCC and your spouse does not qualify to enroll as an unremarried former spouse under title 10 United
States Code For these individuals TCC begins the day after their enrollment in 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
TCC is not available if you move out of a DoD FEHBP Demonstration Project area you cancel your coverage or your coverage is terminated for any reason TCC is not available when the
demonstration project ends
Do I have the 31 day These provisions do not apply to the DoD FEHBP Demonstration Project extension and right
to convert

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 1 800 932 3004 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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PacifiCare of California 2000
NOTES

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PacifiCare of California 2000
NOTES

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PacifiCare of California 2000
Summary of Benefits for PacifiCare of California 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 pay provides Page
Inpatient Hospital Comprehensive range of medical and surgical services with no dollar or day limit Includes
Care 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 7

Extended Care All necessary services up to 100 consecutive days per disability You pay nothing 9

Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days Conditions of inpatient care per year You pay nothing 11
Substance Covered under mental conditions 12 Abuse

Outpatient Comprehensive range of services such as diagnosis and treatment of illness or injury
Care including specialist's care preventive care including well baby care periodic check ups and immunizations as recommended by the American Academy of Pediatrics laboratory

tests and X rays complete maternity care You pay 10 copayment per office visit 10 copayment per house call by a physician 7

Home Health All necessary visits by nurses and home health aids You pay nothing 8 Care
Mental Up to 40 outpatient visits per year You pay varying copayments 11 Conditions
Substance Covered under mental conditions 12 Abuse

Emergency Care Reasonable charges for services and supplies required because of a medical emergency You pay a 35 copayment for each emergency room or urgent care center visit and any
charges for services that are not covered benefits of this Plan 10

Prescription Drugs Drugs prescribed by a Plan physician and obtained at a participating pharmacy You pay 10 copayment for generic and a 10 copayment for brand name drugs per prescription unit
or refill mail order drugs are also covered 12

Dental Care Accidental injury benefit You pay nothing 14
Vision Care One refraction annually You pay a 10 copayment per visit 14
Chiropractic Services Direct access to Chiropractor You pay 5 20 visits per calendar year 9

Out of pocket Copayments are required for a few benefits however after your out of pocket expenses
Maximum reach a maximum of 800 per individual or up to 2,400 per family per calendar year covered benefits will be provided at 100 This copayment maximum does not include

prescription drugs and preventive dental care benefits 4

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PacifiCare of California 2000
2000 Rate Information for
PacifiCare of California

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 postal employees If you are a
career 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

Most of California

Self Only CY1 58.37 19.46 126.47 42.16 69.07 8.76 69.07 8.76
Self and Family CY2 144.90 48.30 313.95 104.65 171.47 21.73 171.47 21.73

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