Pages 1--24 from 5892pruD1R1_Atlanta

For changes
in benefits page 3
see
Serving Atlanta and Macon Georgia areas

Enrollment in this Plan is limited see page 4 for requirements
Enrollment code
EZ1 Self only
EZ2 Self and family

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

Authorized for distribution by the
UNITED STATES OFFICE OF PERSONNEL MANAGEMENT
RETIREMENT AND INSURANCE SERVICE
RI 73 107 1
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Prudential HealthCare HMO Atlanta 2000
Table of Contents Page
Introduction .1
Plain language .1
How to use this brochure .2
Section 1 Health Maintenance Organizations .3
Section 2 How we change for 2000 .3
Section 3 How to get benefits .4
Section 4 What to do if we deny your claim or request for service .6
Section 5 Benefits .7
Section 6 General exclusions Things we don't cover .16
Section 7 Limitations Rules that affect your benefits .16
Section 8 FEHB FACTS .17
Inspector General Advisory Stop Healthcare Fraud .20
Summary of benefits Inside back cover
Premiums Back cover 2
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Prudential HealthCare HMO Atlanta 2000
Introduction

Prudential Health Care Plan of Georgia Inc Prudential HealthCare HMO Atlanta 1425 Union Meeting Road P O Box 3013 Blue Bell PA 19422
This brochure describes the benefits you can receive from Prudential Health Care Plan of Georgia Inc Prudential HealthCare HMO under its contract CS 1938 with the Office of Personnel Management OPM as authorized by the
Federal Employees Health Benefits FEHB law This brochure is the official statement of benefits on which you can rely A person enrolled in this Plan is entitled to the benefits described in this brochure If you are enrolled for Self and Family
coverage each eligible family member is also entitled to these benefits
OPM negotiates benefits and premiums with each plan annually Benefit changes are effective January 1 2000 and are shown on page 3 Premiums are listed at the end of this brochure

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

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

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Prudential HealthCare HMO Atlanta 2000
How to use this brochure

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

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

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

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

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

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

This year you have a right to more information about this Plan care management our networks facilities and providers
If you have a chronic or disabling condition and your provider leaves the Plan at our request you may continue to see your specialist for up to 90 days If your provider leaves
the Plan and you are in the second or third trimester of pregnancy you may be able to continue seeing your OB GYN until the end of your postpartum care You have similar
rights if this Plan leaves the FEHB program See Section 3 How to get benefits for more information

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

Changes to this Your share of the non postal premium will increase by 15.1 for Self Only or 15.1 for Plan Self and Family
Our prescription benefit now includes a 25 non formulary drug copay See page 13
Vision care benefits are no longer provided

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Prudential HealthCare HMO Atlanta 2000
Section 3 How to get benefits
What is this Plan's To enroll with us you must live or work in our service area This is where our providers service area practice Our Atlanta service area includes the following counties Barrow Bartow Butts
Cherokee Clayton Cobb Coweta DeKalb Douglas Fayette Floyd Forsyth Fulton Gwinnett Hall Henry Newton Paulding Rockdale Spalding and Walton

Our Macon service area includes the following counties Bibb Crawford Houston Jones Monroe Peach Twiggs and Wilkinson
Ordinarily you must get your care from providers who contract with us If you receive care outside our service area we will pay only for emergency care We will not pay for any other
health care services
If you or a covered family member move outside of our service area you can enroll in another plan If your dependents live out of the area for example if your child goes to
college in another state you should consider enrolling in a fee for service plan or an HMO that has agreements with affiliates in other areas If you or a family member move you do
not have to wait until Open Season to change plans Contact your employing or retirement office

How much do I You must share the cost of some services This is called either a copayment 10 a set dollar pay for services amount or coinsurance a set percentage of charges Please remember you must pay this
amount when you receive services
After you pay 2,000 in copayments or coinsurance for one family member or 5,000 for two or more family members you do not have to make any further payments for certain
services provided or arranged by the Plan for the rest of the year This is called a catastrophic limit However copayments for your prescription drugs do not count toward
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 submit claims from a provider who doesn't contract with us If you file a claim please send us all of the
documents for your claim as soon as possible You must submit claims by December 31 of the year after the year you received the service Either OPM or we can extend this deadline
if you show that circumstances beyond your control prevented you from filing on time
Who provides Prudential HealthCare HMO is a member company of Aetna US Healthcare my health care
We have four different systems that Atlanta area members can access Each system has primary care physicians specialty care physicians and participating hospitals The four
systems are Emory University System of Health Care Inc Independent System Meridian Medical Group and PROMINIA Health System When selecting a primary care physician
note that this physician will refer you to the specialty care physicians and hospitals within his or her system Members in the Macon area receive care from participating community
doctors
You have a choice of which type of physician will provide your primary care Adults may select either an Internal Medicine or Family Practice physician from the Plan's provider
directory Female members and eligible female dependents over age 13 are also able to access Obstetricians and Gynecologists directly without primary care physician referral
Atlanta area members selecting an OB GYN should remember to choose an OB GYN who is in the same system as their primary care physician Either a Pediatrician or Family
Practitioner may treat children Please note that different family members can select different systems

You will need to let us know which primary care physician you select for each member of the family If you need help in choosing a physician please call us at 800 856 0764 If you
let us know by the 10th of the month your change will be effective the first of the following month We will send you a new ID card You must contact us before seeing your
new physician
All mental health and substance abuse care is coordinated by Quantum Behavioral Healthcare QBH Your primary care physician may refer you to QBH or you may call

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Prudential HealthCare HMO Atlanta 2000
Section 3 How to get benefits continued
QBH directly without a referral QBH's 24 hour telephone number is 770 956 1785 QBH will arrange for a referral to an appropriate mental health or substance abuse provider

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

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

when I join this Plan and are switching to us your former plan will pay for the hospital stay until
You are discharged not merely moved to an alternative care center or The day your benefits from your former plan run out or

The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do I get Your primary care physician will arrange your referral to a specialist You must receive a specialty care referral from your primary care physician before seeing any other doctor or obtaining
special services
When you receive a referral from your primary care physician you must return to that physician after the consultation unless your primary care physician authorizes additional
visits Your primary care physician will develop a treatment plan with you that allows an adequate number of direct access visits with that specialist Do not go to the specialist
unless your primary care physician has arranged for and we have issued an authorization for the referral in advance

You may see mental health providers optometrists dermatologists and obstetricians or gynecologists without a referral We recommend that you confirm with us services from
these providers are covered and are medically necessary
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

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

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

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

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

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

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

independent outside experts and approvals granted by regulatory bodies Your provider may sometimes ask that you sign a form acknowledging that the procedure service or
supply is experimental or investigational This form and any related protocol may also be part of the information we consider After reviewing all pertinent information we make
our determination and notify you of our decision Please contact customer service at 1 800 856 0764 for more specific information

Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing 2 Refer to specific brochure wording explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were unable to make a timely request due to reasons beyond your control

We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing 2 Pay the claim
3 Arrange for a health care provider to give you the service or 4 Ask for more information

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

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

What if I have a Call us at 800 856 0764 and we will expedite our review serious or life
threatening condition and you haven't
responded to my request for service

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

Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold time limits our initial denial or refusal of service You may also ask OPM to review your claim if
1 We do not answer your request within 30 days In this case OPM must receive your request within 120 days of the date you asked us to reconsider your claim
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Prudential HealthCare HMO Atlanta 2000
Section 4 What to do if we deny your claim or request for service continued
2 You provided us with additional information we asked for and we did not answer within 30 days In this case OPM must receive your request within 120 days of the date we
asked you for additional information What do I Your request must be complete or OPM will return it to you You must send the following

send to OPM information
1 A statement about why you believe our decision is wrong based on specific benefit provisions in this brochure

2 Copies of documents that support your claim such as physicians letters operative reports bills medical records and explanation of benefits EOB forms
3 Copies of all letters you sent us about the claim 4 Copies of all letters we sent you about the claim and
5 Your daytime phone number and the best time to call
If you want OPM to review different claims you must clearly identify which documents apply to which claim

Who can make Those who have a legal right to file a disputed claim with OPM are the request
1 Anyone enrolled in the Plan 2 The estate of a person once enrolled in the Plan and
3 Medical providers legal counsel and other interested parties who are acting as the enrolled person's representative They must send a copy of the person's specific written
consent with the review request
Where should I Send your request for review to Office of Personnel Management Office of Insurance mail my disputed Programs Contract Division III P O Box 436 Washington D C 20044

claim to OPM
What if OPM upholds OPM's decision is final There are no other administrative appeals If OPM agrees with our the Plan's denial decision your only recourse is to sue

If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services or supplies
What laws apply Federal law governs your lawsuit benefits and payment of benefits The Federal court will if I file a lawsuit base its review on the record that was before OPM when OPM made its decision on your
claim You may recover only the amount of benefits in dispute
You or a person acting on your behalf may not sue to recover benefits on a claim for treatment services supplies or drugs covered by us until you have completed the OPM
review procedure described above
Your records and Chapter 89 of title 5 United States Code allows OPM to use the information it collects the Privacy Act from you and us to determine if our denial of your claim is correct The information OPM
collects during the review process becomes a permanent part of your disputed claims file and is subject to the provisions of the Freedom of Information Act and the Privacy Act
OPM may disclose this information to support the disputed claim decision If you file a lawsuit this information will become part of the court record

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

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 7 9
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Prudential HealthCare HMO Atlanta 2000
Section 5 Medical and Surgical Benefits continued
What is covered The following services are included and are subject to the office visit copay unless stated continued otherwise

Preventive care including hearing and vision screenings for children through age 17 well baby care and periodic check ups
Sigmoidoscopy screening for colorectal cancer every five years for those age 50 and above
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 or more one mammogram every year In addition to routine screening mammograms are covered when prescribed by the doctor
as medically necessary to diagnose or treat your illness Routine immunizations and boosters
Consultations by specialists Diagnostic procedures such as laboratory tests and X rays no copay applies
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor You pay a 10 copay for the first visit
only The mother at her option may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a caesarian delivery Inpatient stays will be extended
if medically necessary If enrollment in the Plan is terminated during pregnancy benefits will not be provided after coverage under the Plan has ended Ordinary nursery care of
the newborn child during the covered portion of the mothers hospital confinement for maternity will be covered under either Self Only or Self and Family enrollment other
care of an infant who requires definitive treatment will be covered only if the infant is covered under a Self and Family enrollment
Voluntary sterilization and family planning services Implanted time release medications such as Norplant For Norplant and other
internally implanted time release medication there is no charge when the device is implanted during a covered hospitalization There will be no refund of any portion of the
copayment if the implanted time release medication is removed before the end of its expected life
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 artificial joints and
cochlear implants Cornea heart lung single and double heart lung pancreas kidney and liver
transplants allogeneic donor bone marrow transplants autologous bone marrow transplants autologous stem cell and peripheral stem cell support for the following
conditions acute lymphocytic or non lymphocytic leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma advanced neuroblastoma breast cancer
multiple myeloma epithelial ovarian cancer and testicular mediastinal retroperitoneal and ovarian germ cell tumors Transplants are covered when approved by the Medical
Director Related medical and hospital expenses of the donor are covered when the recipient is covered by this Plan
Patients 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 Home health services given or supervised by a Registered Nurse R N including
intravenous fluids and medications when prescribed by your Plan doctor who will periodically review the program for continuing appropriateness and need
Orthopedic devices such as braces Prosthetic devices such as artificial limbs lenses following cataract removal initial
eyeglasses or lenses to replace the loss of the natural lens are covered breast prosthesis and surgical bras and their replacement
Oxygen and rental of equipment for use of oxygen Services and supplies for the treatment of diabetes including outpatient diabetes selfmanagement
training and educational services given by a certified diabetes educator or a board certified endocrinologist Insulin and insulin syringes are covered under the
Prescription Drug Benefits Disposable needles and syringes needed to inject covered prescribed medications
Injectable drugs Medical supplies such as dressings and antiseptics
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers at no additional cost to you

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Prudential HealthCare HMO Atlanta 2000
Section 5 Medical and Surgical Benefits continued
Limited benefits Oral and maxillofacial surgery is provided for non dental 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 All other procedures involving
the teeth or intra oral areas surrounding the teeth are not covered including any dental care involved in treatment of temporomandibular joint TMJ pain dysfunction syndrome

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

Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis for up to two months per condition if significant improvement
can be expected within two months you pay a 10 copay 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 you pay a 10 copay The following types of artificial insemination are covered intravaginal insemination IVI intracervical
insemination ICI and intrauterine insemination IUI You pay a 10 copay The cost of donor sperm is not covered Fertility drugs are covered injectable drugs under Medical and
Surgical Benefits and non injectable drugs under Prescription Drug Benefits Other assisted reproductive technology ART procedures such as in vitro fertilization and embryo
transfer are not covered
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction you pay a 10 copayment per session

Durable medical equipment such as wheelchairs and hospital beds is limited to a lifetime maximum benefit of 10,000 per member Replacement repairs and maintenance of
durable medical equipment not provided for under a manufacturer's warranty or purchase agreement will be covered

Institutes of Quality IQ Program The IQ program provides coverage for sophisticated medical treatments and procedures offered by a network of hospitals and physicians known
for their demonstrated accomplishments in patient outcomes This Program includes a nationwide network for organ transplants bone marrow transplants and brain and spinal
cord injury rehabilitation Under the Program the person's primary care physician must initiate a referral to an institute of quality for covered procedures Participation is subject to
approval by Prudential HealthCare and covered persons must meet pre screening criteria Contact the Plan for further information on the IQ Program

What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance attending school or camp or travel
Reversal of voluntary surgically induced sterility Surgery primarily for cosmetic purposes
Transplants not listed as covered Hearing aids exams to determine the need for hearing aids or the need to adjust them
Homemaker services Foot orthotics
Chiropractic services Blood and blood derivatives not replaced by or for the member
Any eye surgery solely for the purpose of correcting refractive defects of the eye such as nearsightedness myopia farsightedness hyperopia and astigmatism

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 9 11
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Prudential HealthCare HMO Atlanta 2000
Section 5 Hospital Extended Care Benefits
What is covered
Hospital Care The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan doctor You pay nothing All necessary services are
covered including
Semiprivate room accommodations when a Plan doctor determines it is medically necessary the doctor may prescribe private accommodations or private duty nursing care
Specialized care units such as intensive care or cardiac care units
Extended care The Plan provides a comprehensive range of benefits for up to 100 days per condition for all such confinements which are due to the same or related causes and which are separated
by less than three months Coverage is provided when full time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as
determined by a Plan doctor and approved by the Plan You pay nothing All necessary services are covered including

Bed board and general nursing care Drugs biologicals supplies and equipment ordinarily provided or arranged by the
skilled nursing facility when prescribed by a Plan doctor
Hospice Care Supportive and palliative care for a terminally ill member is covered in the home or hospice facility Services include inpatient and outpatient care and family counseling these services
are provided under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness with a life expectancy of approximately six months or less
Benefits for the terminally ill patient are limited to 10,000 per period of care Family counseling services are limited to a maximum of 400

Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines procedures there is a need for hospitalization for reasons totally unrelated to the dental procedure the
Plan will cover the hospitalization but not the cost of the professional dental services Conditions for which hospitalization would be covered include hemophilia and heart
disease the need for anesthesia by itself is not such a condition
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care detoxification diagnosis treatment of medical conditions and medical management of withdrawal
symptoms acute detoxification if the Plan doctor determines that outpatient management is not medically appropriate See page 13 for non medical Substance Abuse Benefits

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

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Prudential HealthCare HMO Atlanta 2000
Section 5 Emergency Benefits
What is a A medical emergency is the sudden and unexpected onset of a condition or an injury that medical emergency 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 please call your primary care physician In extreme the service area emergencies if you are unable to contact your doctor contact the local emergency system
e g the 911 telephone system or go to the nearest hospital emergency room Be sure to tell the emergency room personnel that you are a Plan member so they can notify the Plan
You or a family member must notify the Plan within 48 hours It is your responsibility to ensure that the Plan has been timely notified

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

Plan pays Reasonable charges for emergency services to the extent the services would have been covered if received from Plan providers
You pay 50 per hospital emergency room visit or 25 per urgent care center visit at one of the Meridian Medical Centers for emergency services that are covered benefits of this Plan If
the emergency results in an admission to a hospital the emergency room copay is waived
Emergencies outside Benefits are available for any medically necessary health service that is immediately the service area required because of injury or unforeseen illness

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

To be covered by this Plan any follow up care recommended by non Plan providers must be approved by the Plan or provided by Plan providers
Plan pays Reasonable charges for emergency care services to the extent the services would have been covered if received from Plan providers
You pay 50 per hospital emergency room visit or 25 per urgent care center visit for emergency services that are covered benefits of this Plan Urgent care services rendered outside the
service area must be coordinated through the Prudential National Service Hotline in order for the 25 copay to apply If the emergency results in an admission to a hospital the
emergency room copay is waived
What is covered Emergency care at a doctor's office or an urgent care center Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service approved by the Plan
What is not covered Elective care or non emergency care Emergency care provided outside the service area if the need for care could have been
foreseen before leaving the service area 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 non Plan providers emergency care upon receipt of their claims Physician claims should be submitted on the

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Prudential HealthCare HMO Atlanta 2000
Section 5 Emergency Benefits continued
Filing claims for HCFA 1500 claim form If you are required to pay for the services submit non Plan providers itemized bills and your receipts to the Plan along with an explanation of the services and the
continued 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
Portability If you are away from home and require medical care other than routine physical exams Reciprocity immunizations and non emergency maternity care you can access a network facility in the
area you are visiting You will receive this care at a maximum benefit level as if you were at home free of bills and claim forms

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

Section 5 Mental Conditions Substance Abuse Benefits
Quantum Behavioral Health's 24 hour telephone number is 770 956 1785 QBH will arrange for a referral to an appropriate mental health or substance abuse provider All treatment must be coordinated by QBH who will determine
and authorize the appropriate number of visits
Mental conditions
What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions including the treatment of mental
illness or disorders Diagnostic evaluation
Psychological testing Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Outpatient care Up to 20 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year you pay 50 of charges per visit for each covered visit all charges
thereafter
Inpatient care Up to 30 days of hospitalization each calendar year you pay nothing for the first 30 daysall charges thereafter

Intermediate care Intermediate care accumulates toward the 30 days per calendar year limit for inpatient care Each two days of intermediate care will count as one inpatient day you pay nothing for up
to 60 days in combination with the inpatient days above for a total of 30 inpatient days all charges thereafter Intermediate care consists of continuous treatment in a facility for not
less than 3 hours nor more than 12 hours in any 24 hour period It does not include a hospital inpatient stay

What is not covered Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to significant improvement through relatively short term treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless determined by a Plan doctor to be necessary and appropriate
Psychological testing when not medically necessary to determine the appropriate treatment of a short term psychiatric condition

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 12 14
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Prudential HealthCare HMO Atlanta 2000
Section 5 Mental Conditions Substance Abuse Benefits continued
Substance abuse
What is covered This Plan provides medical and hospital services such as acute detoxification services for the medical non psychiatric aspects of substance abuse including alcoholism and drug
addiction the same as for any other illness or condition and to the extent shown below the services necessary for diagnosis and treatment

Outpatient care Up to 20 outpatient visits to Plan providers for treatment each calendar year you pay 50 of charges per visit for each covered visit all charges thereafter
Inpatient care Up to 30 days per calendar year in a substance abuse rehabilitation intermediate care program in an alcohol detoxification or rehabilitation center approved by the Plan you pay
nothing for the first 30 days all charges thereafter
What is not covered Treatment that is not authorized by a Plan doctor

Section 5 Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained at a participating pharmacy will be dispensed for up to a 30 day supply or one commercially prepared unit
i e one inhaler one vial ophthalmic medication or insulin You pay a 5 copay per prescription unit or refill for generic formulary drugs or a 15 copay per prescription unit
or refill for brand name formulary drugs or a 25 copay per prescription unit or refill for non formulary drugs However in no event will the copay exceed the cost of the
prescription
Maintenance drugs and some oral contraceptive drugs prescribed by a Plan or referral doctor can also be obtained via a mail order program for up to a 90 day supply per unit or
refill a copay applies to each 30 day supply You pay a 5 copay per prescription unit or refill for generic formulary drugs or a 15 copay per prescription unit or refill for brand
name formulary drugs or a 25 copay per prescription unit or refill for non formulary drugs

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

Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary Non formulary drugs will be covered when prescribed by a Plan doctor subject
to the non formulary copay To obtain additional information about our formulary or our mail order program call Prudential HealthCare customer service at 1 800 856 0764 or visit
our website at www aetnaushc com pruhealthcare
Formulary The Prudential Health Care Drug Formulary was developed and is maintained by the development Prudential HealthCare National Pharmacy and Therapeutics committee P T with the
understanding that a well constructed formulary enhances quality of care The P T committee evaluates the clinical use of drugs and develops policies and procedures for
developing new drug therapies and managing the formulary The P T is also responsible for conducting therapeutic class reviews and analyzing new drugs as they enter the market
The formulary reflects our medical and pharmaceutical experience in formulary management and rigorous reviews of individual clinical studies

The following are examples of what a copay applies to
Up to a 30 day supply of tablets capsules and liquids to be taken orally or as indicated for use by the Food and Drug Administration FDA For example Diflucan VC is FDA
indicated as a single dose treatment and a copay will be charged for each tablet The treatment usage for many antibiotics will be for a 10 day supply or less for which one
copay would apply a manufacturer's standard 10 milliliter vial of insulin
insulin syringes a copay applies to each package of 100 a package of no more than 15 milliliters of any optic or opthalmic product

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 13 15
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Prudential HealthCare HMO Atlanta 2000
Section 5 Prescription Drug Benefits continued
Examples a manufacturer's smallest standard package of nasal or oral inhaler continued a manufacturer's smallest standard package of nebulizer solution
1 manufacturer's smallest standard package of liquid or solid rectal or vaginal medication
1 manufacturer's smallest standard package containing no more than 60 milliliters of topical solutions or lotions
1 manufacturer's smallest standard package containing no more than 60 grams of topical ointments or creams
Up to a 30 day supply of patches a copay applies to each manufacturer's standard package
1 package of oral contraceptives
Covered medications Drugs for which a prescription is required by law and accessories include Oral contraceptive drugs up to a 90 day supply per refill of maintenance and oral
contraceptive drugs may be obtained with a copay applied to each 30 day supply filled at the local participating pharmacy
Diaphragms with a prescription Insulin with a copay charge applied to each vial
Disposable needles and syringes for insulin you pay a separate copay Fertility drugs

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

Limited benefits Sexual dysfunction drugs have dispensing limitations For complete details please call Prudential HealthCare customer service at 1 800 856 0764
What is not covered Drugs available without prescription or for which there is a nonprescription equivalent available
Drugs obtained at a non Plan pharmacy except out of area emergencies Vitamins and nutritional substances which can be obtained without a prescription
Drugs for cosmetic purposes Drugs to enhance athletic performance
Smoking cessation drugs and medication

Section 5 Other Benefits
Dental care
Accidental injury Restorative services and supplies necessary to promptly repair or replace sound natural
benefit teeth are covered The need for these services must result from an accidental injury You pay a 10

What is not covered Other dental services not shown as covered

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 14 16
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Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB program but are made available to all enrollees and family members who are members of the Plan The cost of the benefits described on this
page is not included in the FEHB premium any charges for these services do no count toward any FEHB deductibles or outof pocket maximums These benefits are not subject to the FEHB disputed claims procedures

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

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

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

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

Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the
payments On occasion you may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled with us

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

If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration SSA office or request it from SSA at 1 800 638 6833
Other group When anyone has coverage with us and with another group health plan it is called double insurance coverage coverage You must tell us if you or a family member has double coverage You must also
send us documents about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other plan is secondary it pays benefits next We decide which insurance is primary
according to the National Association of Insurance Commissioners Guidelines
If we pay second we will determine what the reasonable charge for the benefit should be After the first plan pays we will pay either what is left of the reasonable charge or our
regular benefit whichever is less We will not pay more than the reasonable charge If we are the secondary payer we may be entitled to receive payment from your primary plan

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

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Prudential HealthCare HMO Atlanta 2000
Section 7 Limitations Rules that affect your benefits continued
When others are When you receive money to compensate you for medical or hospital care for injuries or responsible for injuries illness that another person caused you must reimburse us for whatever services we paid for
We will cover the cost of treatment that exceeds the amount you received in the settlement If you do not seek damages you must agree to let us try This is called subrogation If you
need more information contact us for our subrogation procedures
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover
you we are the primary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE coverage

Workers compensation We do not cover services that
You need because of a workplace related disease or injury that the Office of Workers Compensation Programs OWCP or a similar Federal or State agency determine they
must provide OWCP or a similar agency pays for through a third party injury settlement or other
similar proceeding that is based on a claim you filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment we will provide your benefits as long as you use our providers

Medicaid We pay first if both Medicaid and this Plan cover you
Other Government We do not cover services and supplies that a local State or Federal Government agency Agencies directly or indirectly pays for

Section 8 FEHB FACTS
You have a right to information about your HMO
OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right to information about your health plan its networks providers and facilities You can also find out about care management which
includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's website www opm gov lists the specific types of information that we must make
available to you
If you want specific information about us call 800 856 0764 or write to Prudential HealthCare 1425 Union Meeting Road P O Box 3013 Blue Bell PA 19422 You may also contact us by fax at 215 775 5870 or visit our website at
www aetnaushc com pruhealthcare
Where do I get Your employing or retirement office can answer your questions and give you a Guide to information about Federal Employees Health Benefits Plans brochures for other plans and other materials you

enrolling in the need to make an informed decision about FEHB Program
When you may change your enrollment How you can cover your family members

What happens when you transfer to another Federal agency go on leave without pay enter military service or retire
When your enrollment ends and The next Open Season for enrollment

We don't determine who is eligible for coverage and in most cases cannot change your enrollment status without information from your employing or retirement office
When are my The benefits in this brochure are effective on January 1 If you are new to this plan your benefits and coverage and premiums begin on the first day of your first pay period that starts on or after
premiums effective January 1 Annuitants premiums begin January 1

What happens When you retire you can usually stay in the FEHB Program Generally you must have been when I retire enrolled in the FEHB Program for the last five years of your Federal service If you do not

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Prudential HealthCare HMO Atlanta 2000
Section 8 FEHB FACTS continued
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 available your unmarried dependent children under age 22 including any foster or step children your
for my family and me employing or retirement office authorizes coverage for Under certain circumstances you may also get coverage for a disabled child 22 years of age or older who is incapable of selfsupport

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

Are my medical and We will keep your medical and claims information confidential Only the following will claims records have 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 Worker's 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 We will send you an Identification ID card Use your copy of the Health Benefits Election cards Form SF 2809 or the OPM annuitant confirmation letter until you receive your ID card
You can also use an Employee Express confirmation letter
What if I paid a Your old plan's deductible continues until our coverage begins deductible under

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

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

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

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

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Prudential HealthCare HMO Atlanta 2000
Section 8 FEHB FACTS continued
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
How do I enroll If you leave Federal service your employing office will notify you of your right to enroll in TCC under TCC You must enroll within 60 days of leaving or receiving this notice whichever is
later
Children You must notify your employing or retirement office within 60 days after your child is no longer an eligible family member That office will send you information about
enrolling in TCC You must enroll your child within 60 days after they become eligible for TCC or receive this notice whichever is later

Former spouses You or your former spouse must notify your employing or retirement office within 60 days of one of these qualifying events
Divorce Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about enrolling in TCC Your former spouse must enroll within 60 days after the event which
qualifies them for coverage or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse notify your employing or retirement office within the 60 day deadline

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

If you leave Federal service your employing office will notify you if individual coverage is available You must apply in writing to us within 31 days after you receive this notice
However if you are a family member who is losing coverage the employing or retirement office will not notify you You must apply in writing to us within 31 days after you are no
longer eligible for coverage
Your benefits and rates will differ from those under the FEHB Program however you will not have to answer questions about your health and we will not impose a waiting period or
limit your coverage due to pre existing conditions

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Prudential HealthCare HMO Atlanta 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 Certificate of Group Coverage that indicates how long you have been enrolled with us You can use this
Health Plan Coverage certificate when getting health insurance or other health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new plan must reduce or
eliminate waiting periods limitations or exclusions for health related conditions based on the information in the certificate

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

Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for services you did not receive billed you twice for the same service or misrepresented any information do the
following Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 800 856 0764 and explain the situation If we do not resolve the issue call or write

THE HEALTH CARE FRAUD HOTLINE 202 418 3300
U S Office of Personnel Management Office of the Inspector General Fraud Hotline
1900 E Street NW Room 6400 Washington D C 20415

Penalties for Fraud Anyone who falsifies a claim to obtain FEHB Program benefits can be prosecuted for fraud Also the Inspector General
may investigate anyone who uses an ID card if they Try to obtain services for a person who is not an eligible family member or
Are no longer enrolled in the Plan and try to obtain benefits
Your agency may also take administrative action against you

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

Benefits Plan pays provides Page
Inpatient care Hospital Comprehensive range of medical and surgical services without dollar or day limit Includes in hospital doctor care room and board general
nursing care private room and private nursing care if medically necessary diagnostic tests drugs and medical supplies use of operating
room intensive care and complete maternity care You pay nothing 10
Extended care All necessary services up to 100 days per condition You pay nothing 10
Mental conditions Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient
care per year You pay nothing 12
Substance Abuse Up to 30 days per year in a substance abuse treatment program You pay nothing 13

Outpatient care Comprehensive range of services such as diagnosis and treatment of illness or injury including specialist's care preventive care including
well baby care periodic check ups and routine immunizations laboratory tests and X rays complete maternity care You pay a
10 copay per office visit 10 per house call by a doctor 7
Home health care All necessary visits by nurses and health aides You pay nothing 8
Mental conditions Up to 20 outpatient visits per year You pay 50 of charges per visit 12
Substance abuse Up to 20 outpatient visits per year You pay 50 of charges per visit 13

Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 50 copay to the hospital for each
emergency room visit and any charges for services that are not covered by this Plan 11

Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5 copay per prescription unit or refill for a generic formulary
drug a 15 copay per prescription unit or refill for a brand name drug or a 25 copay per prescription unit or refill for a non formulary drug 13

Dental care Accidental injury benefit you pay a 10 copay per visit 14
Out of pocket maximum Copayments are required for a few benefits however after your out of pocket expenses reach a maximum of 2,000 per Self Only or 5,000
per Self and Family enrollment per calendar year covered benefits will be provided at 100 This copay maximum does not
include charges for prescription drugs 4

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2000 Rate Information for
Prudential HealthCare HMO Atlanta

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 EZ1 60.03 20.01 130.07 43.35 71.04 9.00 71.04 9.00
Self and Family EZ2 164.25 54.75 355.88 118.62 194.36 24.64 194.36 24.64

RRD 8104417A
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