Pages 1--28 from 6010pruD1R1_Oklahoma

For changes its
in benef page 3
see

Serving Oklahoma City and Tulsa Oklahoma Areas

Enrollment in this Plan is limited see page 4 for requirements
Oklahoma City Enrollment code
RR1 Self only
RR2 Self and family

Tulsa Enrollment code
RS1 Self only
RS2 Self and family

Special Notice Prudential HealthCare HMO Oklahoma City and Prudential HealthCare HMO Tulsa have been consolidated into a single Plan with 2 separate enrollment codes There may be substantial changes to your benefits
Please read your brochure carefully We have also greatly reduced the Oklahoma City service and enrollment area You must choose another health plan during open season if you live in one of the following counties Alfalfa Atoka
Beaver Beckham Bryan Carter Choctaw Cimmaron Coal Cotton Custer Ellis Grant Greer Harmon Harper Hughes Jackson Johnston Kay Kiowa Murray Noble Pushmataha Roger Mills Stephens Texas Tillman Washita
and Woods If you do not change during open season you will have to travel to the existing service area in order to received full plan benefits

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 73 108 1
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Prudential HealthCare HMO 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 .8
Section 6 General exclusions Things we don't cover .17
Section 7 Limitations Rules that affect your benefits .17
Section 8 FEHB FACTS .18
Inspector General Advisory Stop Healthcare Fraud .22
Summary of benefits Inside back cover
Premiums Back cover 2
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Prudential HealthCare HMO 2000
Introduction

Prudential Health Care Plan Inc 1425 Union Meeting Road
P O Box 3013 Blue Bell PA 19422

This brochure describes the benefits you can receive from Prudential HealthCare Plan Inc hereafter referred to as Prudential HealthCare HMO under its contract CS 1939 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 HealthCare HMO 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 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 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 when you receive services you must pay copayments and coinsurance listed in this brochure When you receive emergency services
you may have to submit claim forms
You should join an HMO because you prefer the plan's benefits not because a particular provider is available You cannot change plans because a provider leaves our Plan We cannot guarantee that any one physician hospital or other provider
will be available and or remain under contract with us Our providers follow generally accepted medical practice when prescribing any course of treatment

Section 2 How we change for 2000
Program wide To keep your premium as low as possible OPM has set a minimum copay of 10 for all 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
You may review and obtain copies of your medical records on request If you want copies of your medical records ask you 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 the record 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 For enrollment code RR your share of the non postal premium increased by 23 for either Plan Self Only or Self and Family For enrollment code RS your share of the non postal
premium increased by 19 for either Self Only or Self and Family
We have consolidated benefits for Prudential HealthCare HMO Oklahoma City and Prudential HealthCare HMO into a single contract All members are covered under a
single package of benefits Please read your brochure carefully so that you are aware of all benefit changes

We have eliminated the following counties from the Oklahoma City service enrollment and service area RR Alfalfa Atoka Beaver Beckham Bryan Carter Choctaw Cimmaron Coal
Cotton Custer Ellis Grant Greer Harmon Harper Hughes Jackson Johnston Kay Kiowa Murray Noble Pushmataha Roger Mills Stephens Texas Tillman Washita and Woods If
you live in one of these counties you should change health plans during open season
The office visit copay will be 10 under the Medical and Surgical Benefits Previously the office visit copay was 5.00 for members in the Oklahoma City and Tulsa areas

Under your Prescription Drug Benefits the copays are now 5.00 generic formulary 15.00 name brand formulary and 25.00 non formulary per prescription unit or refill up to a 30
day supply You may obtain up to a 90 day supply of certain maintenance drugs through our mail order pharmacy program for a single copay Adding the non formulary copay eliminates
the procedure for requesting non formulary drugs Previously the prescription drug copays for Oklahoma City and Tulsa were 5.00 generic and 10.00 name brand See page 14

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Prudential HealthCare HMO 2000
Section 2 How we change for 2000 continued
Under the Medical and Surgical Limited Benefits for the Diagnosis and Treatment of Infertility injectable fertility drugs are covered at 50 Oral drugs that treat infertility are
covered under the Prescription Drug Benefits subject to applicable copays Previously drugs to treat infertility were not a covered benefit for either Oklahoma City or Tulsa See
page 10
The out of pocket maximum will be 500 for Self only and 1,500 per Self and Family enrollment Previously the out of pocket maximum was 400 for Self only and 1,200 for
Self and Family in the Tulsa area See page 5
We provide coverage for the treatment of Severe Mental Illness in the same manner as for any covered physical illness See pages 10 11 and 13

Hearing aids are now covered for children up to age 13 See page 9
Members pay 50 for allergy testing Previously members in Tulsa paid nothing for covered allergy testing See page 8

Vision Care Benefits have been eliminated Previously members in the Tulsa area were entitled to routine vision care benefits
Smoking cessation therapy that requires a prescription is covered under the Prescription Drug Benefits at the applicable generic name brand and non formulary copay Coverage is
limited to one 90 day course of treatment per lifetime administered by a Plan doctor

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 Oklahoma City RR service area is Blaine Caddo Canadian Cleveland Comanche Dewey Garfield Garvin Grady Kingfisher Lincoln Logan Major McClain Oklahoma
Payne Pontotoc Pottawatomie Seminole and Woodward counties
Our Tulsa RS service area consists of the following cities and zip codes Avant 74001 Beggs 74421 Bixby 74008 Broken Arrow 74011 74014 Bryant 74880 Catoosa
74015 Chelsa 74016 Claremore 74017 74018 Cleveland 74202 Chouteau 74337 Collinsville 74021 Coweta 74431 Dewar 74431 Eram 74422 Foyil 74031
Gleenpool 74033 Haskell 74436 Henryetta 74437 Inola 74036 Jenks 74037 Kellyville 74039 Kiefer 74041 Leonard 74043 Mannford 74044 Morris 74445
Oakhurst 74050 Okmulgee 74447 Oologah 74053 Osage 74054 Owasso 74055 Porter 74454 Preston 74456 Prue 74060 Pryor 74361 74362 Sand Springs
74063 Sapulpa 74066 74067 Schulter 74460 Skiatook 74070 Sperry 74073 Talala 74080 Terlton 74080 Tulsa 74101 74121 74125 74138 74145 74159 74169
74171 Vera 74082 and Wagoner 74467 74477
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 For emergency or urgent
care outside of the service area members are instructed to call the National Hotline at 1 800 526 2963 for advance authorization 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

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Prudential HealthCare HMO 2000
Section 3 How to get benefits continued
How much do I You must share the cost of some services This is called either a copayment a set dollar pay for services amount or coinsurance a set percent of charges Please remember you must pay this
amount when you receive services except for laboratory tests and X rays
After you pay 500 in copayments or coinsurance for one family member or 1,500 for two or more family members you do not have to make any further payments for certain services
for the rest of the year This is called a catastrophic limit However copayments or coinsurance for your prescription drugs 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 Health Care Plan Inc is a Mixed Model Prepayment MMP Plan with my health care two service areas Oklahoma City RR and Tulsa RS

In the Oklahoma City RR service area our Plan physicians have individual practices or are part of a medical group Our network includes hospitals for inpatient care an expanded
list of pharmacies and specialists for referral care
In the Tulsa area you may receive care from Medical Care Associates of Tulsa MCAT Warren Clinic and OMNI Medical Group These medical groups have physicians in Family
Practice General Medicine Internal Medicine and Pediatrics If you are outside the metropolitan Tulsa area you have access to individual Plan practitioners

Each Prudential HealthCare HMO member must select a primary care doctor from our provider directory whom they see by appointment Your primary care doctor directs all of
your specialty care

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 We will provide benefits for covered services only when the services are medically necessary to prevent diagnose or treat your illness or condition For mental
health services for members in the Oklahoma City area a member must call Merit Behavioral Health MBC at 1 800 553 3009 for preauthorization of mental health
services For Tulsa members a member may contact Columbia Tulsa Regional Medical Center directly at 918 599 5880 or Laureate Psychiatric Clinic at 918 491 5600 for
mental health or substance abuse services A woman may see her Plan gynecologist for her annual routine examination or confirmed pregnancy without a referral

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Prudential HealthCare HMO 2000
Section 3 How to get benefits continued
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 It is the responsibility of
your primary care doctor to obtain all necessary authorizations from the Plan before referring you to a specialist or making arrangements for hospitalization

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 if Call your primary care physician who will arrange for you to see another specialist You 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 to serious illness and my continue seeing your provider for up to 90 days after we notify you that we are terminating

provider leaves the our contract with the provider unless the termination is for cause If you are in the second Plan or this Plan 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
your postpartum care
How do you Your physician must get our approval before sending you to a hospital referring you to a authorize medical specialist or recommending follow up care Before giving approval we consider if the

services service is medically necessary to prevent diagnose or treat your illness or condition 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 if a service is In 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 in explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show that you were unable to make a timely request due to reasons beyond your control

We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing 2 Pay the claim

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Prudential HealthCare HMO 2000
Section 4 What to do if we deny your claim or request for service continued
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 your condition is serious or life threatening call OPM at 202 606 0191 They will denied my request expedite the review of your dispute with us Serious or life threatening conditions are ones
for care and my that may cause permanent loss of bodily functions or death if they are not treated as soon as condition is serious 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
2 You provided us with additional information we asked for and we do not answer within 30 days In this case OPM must receive your request within 120 days of the date we
asked you for additional information
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 Send your request for OPM review to Office of Personnel Management Office of I send my Insurance Programs Contract Division 3 P O Box 436 Washington D C 20044

disputed claim
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

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Prudential HealthCare HMO 2000
Section 4 What to do if we deny your claim or request for service continued
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 nothing 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

The following services are included and are subject to the office visit copayment unless otherwise stated
Preventive care including well baby care and periodic check ups Sigmoidoscopy screening for colorectal cancer at age 50 and every five years
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
Routine immunizations and boosters Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays Complete obstetrical maternity care for all covered females including prenatal
delivery and postnatal care by a Plan doctor the 10 copayment applies to the first prenatal office 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 cesarean delivery Inpatient stays will be extended if medically necessary If you terminate enrollment in the Plan during
pregnancy benefits will not be provided after coverage under the Plan has ended Ordinary nursery care of the newborn child during the covered portion of the mother's
hospital confinement for maternity will be covered under either a Self Only or Self and Family enrollment Other care of an infant who requires definitive treatment will be
covered only if the infant is covered under a Self and Family enrollment Voluntary sterilization and family planning services and insertion of IUDs
Diagnosis and treatment of diseases of the eye Allergy testing and treatment including testing and treatment materials such as allergy
serum you pay 50 of charges The cost of allergy serum is covered in full The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart lung lung single or double kidney pancreas 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

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Prudential HealthCare HMO 2000
Section 5 Medical and Surgical Benefits continued
What is covered advanced non Hodgkin's lymphoma advanced neuroblastoma breast cancer multiple continued myeloma epithelial ovarian cancer and testicular mediastinal retroperitoneal and ovarian
germ cell tumors Transplants are covered when approved by the Plan's Medical Director Related medical and hospital expenses of the donor are covered when the recipient is
covered by this Plan Women who undergo mastectomies may at their option have this procedure performed
on an inpatient basis and remain in the hospital for up to 48 hours after the procedure Dialysis
Chemotherapy radiation therapy and inhalation therapy Surgical treatment of morbid obesity
Orthopedic devices such as braces You pay 20 of charges Prosthetic devices such as artificial limbs breast prostheses and surgical bras as well as
their replacement and initial lenses or eyeglasses following cataract removal You pay 20 of charges
Durable Medical equipment such as hospital beds and wheelchairs Replacement repairs and maintenance of durable medical equipment not provided for under a
manufacturer's warranty or purchase agreement will be covered You pay 20 of charges
Supplies including needles and syringes needed for injecting prescribed medications dressing and colostomy bags You pay 20 of charges
Home health services of nurses and health aides including intravenous fluids and medications when prescribed by your Plan doctor who will periodically review the
program for continuing appropriateness and need 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 Oxygen and rental of equipment for use of oxygen You pay 20 of charges
Diabetic supplies including needles blood glucose monitors injection aids cartridges for the legally blind insulin pumps and equipment oral agents for controlling blood
sugar insulin infusion devices podiatric appliances and services for prevention of complications associated with diabetes glucose test tablets and test tape Benedicts
solution or equivalent and acetone test tablets You pay 20 of charges Hearing aids for children up to age 13
Chiropractic services Implanted time release medications such as Norplant devices you pay an office copay
of 10 and 20 of charges for the implanted medication There is no charge when the device is implanted during a covered hospitalization Amounts that you pay are not
refundable even if the implanted time release medication is removed before the end of its expected life Coverage is limited to one 1 implanted time release medication within
the expected lifetime of the product
Limited Benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or
surgical procedures occurring within or adjacent to the oral cavity or sinuses including but not limited to treatment of fractures and excision of tumors and cysts All other procedures
involving the teeth or intra oral areas surrounding the teeth are not covered including 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 Outpatient rehabilitative therapy is limited to the greater of
services provided within 60 consecutive days or 60 visits for any one condition in a calendar year as long as significant improvement can be expected through short term
therapy You pay a 10 copayment 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

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Prudential HealthCare HMO 2000
Section 5 Medical and Surgical Benefits continued
Limited Benefits Diagnosis and treatment of infertility as well as artificial insemination intravaginal continued insemination IVI intracervical insemination ICI and intrauterine insemination IUI
are covered you pay 50 of charges We do not cover the cost of donor sperm harvesting storage and or manipulation of eggs and sperm Injectable Fertility drugs are covered you
pay 50 Oral fertility drugs are covered under the Prescription Drug Benefits and subject to the applicable copays All other assisted reproductive technology ART procedures such
as in vitro fertilization and embryo transfer etc are not covered
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is provided at a Plan facility on an inpatient or outpatient basis for up to two
months per condition You pay a 10 copay per outpatient session in an office setting and nothing in a non office setting

The Institutes of Quality 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 The IQ Program includes a nationwide network for organ transplants bone marrow transplants and brain and spinal cord injury
rehabilitation Under the IQ Program your primary care doctor initiates a referral to an institute of quality for covered procedures You must meet certain pre screening criteria
Your participation is strictly subject to approval by Prudential HealthCare You may contact us for further information on the IQ Program

Diabetes self management training is covered as long it 1 is needed upon the diagnosis of diabetes or if there is a significant change in the patient's condition 2 is supervised by a
doctor legally authorized to provide such training and 3 is completed by the patient You pay the 10 office visit copay

Severe Mental Illness treatment is covered in the same manner as other physical illnesses and disorders You pay 10 per covered outpatient visit and nothing for covered inpatient
treatment Severe mental illness means only the following biologically based mental illnesses as described in the most recent edition of the Diagnostic and Statistical Manual of
Mental Disorders schizophrenia bipolar disorder manic depressive illness major depression disorder obsessive compulsive disorder and schizoaffective disorder Mental
illnesses that are not defined as Severe Mental Illness are covered under the Mental Conditions Substance Abuse Benefits

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
Plastic surgery primarily for cosmetic purposes Transplants not listed as covered
Any eye surgery solely for the purpose of correcting refractive defects of the eye such as nearsightedness myopia farsightedness hyperopia and astigmatism
Hearing aids for persons who are 13 years or older Foot orthotics When not related to diabetes
Homemaker services Long term rehabilitative therapy
Blood and blood derivatives replaced by or for the patient

Section 5 Hospital Extended Care Benefits
What is covered
Hospital care We provide 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

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Prudential HealthCare HMO 2000
Section 5 Hospital Extended Care Benefits continued
Extended care We provide 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 hospice care 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 Each person is entitled to a maximum
benefit of 7,400 per period of care Up to 200 in counseling services may be provided to the family unit within three months after the death of the patient

Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
Limited benefits
Inpatient dental We cover hospitalization for certain dental procedures is covered when a Plan doctor procedures determines there is a need for hospitalization for reasons totally unrelated to the dental
procedure Although we will cover the hospitalization we will not cover 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 14 for nonmedical substance abuse benefits

Severe Mental Hospitalization is covered in the same manner as other physical illnesses and disorders You Illness pay nothing for covered inpatient treatment Severe mental illness means only the following
mental illnesses as described in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders schizophrenia bipolar disorder manic depressive illness
major depression disorder obsessive compulsive disorder and schizoaffective disorder Mental illnesses that are not defined as Severe Mental Illness are covered under the
Mental Conditions Substance Abuse Benefits
What is not covered Personal comfort items such as telephone and television Blood and blood derivatives replaced by or for the patient
Custodial care rest cures domiciliary or convalescent care

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Prudential HealthCare HMO 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 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 we 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 doctor 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 us You or
a family member must notify us within 48 hours unless it was not reasonable possible to do so It is your responsibility to ensure that we have been timely notified

If you need to be hospitalized we must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to notify us 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

We pay 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 for emergency services that are covered benefits of this Plan If the emergency results in admission to a
hospital we waive the emergency care copay
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 we must be notified within 48 hours or on the first working day following your admission unless it was not reasonably possible to notify us 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
We pay 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 for the 25 copay to apply If the emergency results in admission to a hospital we waive the
emergency care copay
What is covered Emergency care at a doctor's office or an urgent care center minor emergency 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

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Section 5 Emergency Benefits continued
Filing claims for With your authorization we will pay benefits directly to the providers of your emergency non Plan providers care upon receipt of their claims Physician claims should be submitted on the HCFA 1500
claim form If you are required to pay for the services submit itemized bills and your receipts to us along with an explanation of the services and the identification information
from your ID card
We will send payment to you or the provider if you did not pay the bill unless we deny benefits for the claim If we deny benefits we will send you a written notice of our
decision including the reasons for the denial and the provisions of the contract on which we based our decision If you disagree with us you may ask us to reconsider our decision 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 physicals Reciprocity immunizations and non emergency maternity care you can use any Prudential HealthCare
network facility in the area you are visiting You will receive this care at the 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 doctor or medical group to obtain permission for out of area
care In life threatening emergencies we recommend that you seek appropriate treatment immediately However you or a member of your family must notify your primary care
doctor within 48 hours concerning the emergency care you received Contact the Prudential HealthCare office in the city you are visiting or the Prudential
National Hotline 1 800 526 2963 to obtain a referral to a local participating physician 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
Members must contact Merit Behavioral Care MBC at 800 553 3009 for access to mental health substance abuse services if you live or work in the Oklahoma City area RR

If you live or work in the Tulsa area RS you must contact Columbia Tulsa Regional Medical Center directly at 918 599 5880 or Laureate Psychiatric Clinic at 918 491 5600 for mental health or substance abuse services

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 40 visits for individual counseling with Plan doctors consultants or other psychiatric personnel each calendar year you pay nothing for the first 3 visits and 20 of charges for
the next 37 visits all charges thereafter Group counseling visits may be substituted for individual visits on a 3 for 2 basis

Inpatient care Up to 30 days of hospitalization or 60 days of day treatment each calendar year You pay nothing for first 5 days and 20 of charges for next 25 days of inpatient treatment OR you
pay nothing for first 10 days and 20 of charges for next 50 days of day treatment all charges thereafter

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Section 5 Mental Conditions Substance Abuse Benefits continued
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

Severe Mental Illness is covered under the Medical and Surgical Limited Benefit or Hospital Extended Care Benefits Severe mental illness means only the following
biologically based mental illnesses as described in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders schizophrenia bipolar disorder
manic depressive illness major depression disorder obsessive compulsive disorder and schizoaffective disorder Mental illnesses that are not defined as Severe Mental
Illness are covered under the Mental Conditions Substance Abuse Benefits
Substance Abuse
What is covered We provide 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 Services for the psychiatric aspects are provided in conjunction with the mental conditions benefits show above Outpatient
visits to Plan providers for treatment are covered as well as inpatient services necessary for diagnosis and treatment The mental conditions visit day limitations and copayments apply
to any covered substance abuse care
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 Plan 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 name
brand 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 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 also include other conditions

Up to a 90 day supply of maintenance drugs and oral contraceptive drugs prescribed by a Plan doctor may be obtained from our mail order pharmacy You pay a 5 copay per
prescription unit or refill for generic formulary drugs or a 15 copay per prescription unit or refill for name brand formulary drugs or a 25 copay per prescription unit or refill for
non formulary drugs
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 25 non formulary copay If you would like a copy of the prescription drug formulary call Prudential HealthCare customer service at 1 800 856 0764 or visit our
website at www aetnaushc com pruhealthcare
Formulary Our formulary was developed and is maintained by the Prudential HealthCare National development Pharmacy and Therapeutics P T committee 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 committee 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

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Prudential HealthCare HMO 2000
Section 5 Prescription Drug Benefits continued
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
indicatedfor use by the Food and Drug Administration FDA For example Diflucan VC is FDA indicated as a single dose treatment and 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 a manufacturer's smallest standard package of nasal or oral inhaler
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 60milliliters 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
1 diaphragm unit
Covered medications Drugs for which a prescription is required by law and accessories include Oral contraceptives 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
FDA approved prescriptions and contraceptive devices including diaphragms with a prescription
Insulin with a copay charge applied to each vial Disposable needles and syringes included with the insulin prescription are covered up to
a 30 day supply you pay an additional copay Non injectable fertility drugs injectables are covered under the Medical and Surgical
Benefits
Diabetic supplies except insulin intervenous 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

Smoking cessation aids Smoking cessation therapy that requires a prescription is covered subject to the following
limitations You pay a 5 copay for each generic formulary supply and a 15 copay for each name brand formulary supply and a 25 copay for each non formulary supply
Lifetime coverage is limited to one 90 day course of treatment to be administered through a Plan doctor

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 to enhance athletic performance Drugs for cosmetic purposes
Non prescription smoking cessation drugs and medication

Section 5 Other Benefits
Dental Care
What is covered
Accidental injury Restorative services and supplies necessary to promptly repair and replace sound natural benefit teeth are covered The need for these services must result from and accidental injury You
pay a 10 copayment per office visit
What is not covered Other dental services not shown as covered

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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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 claims 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 by the open season deadline 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 Benefit
Network Systems at 1 800 391 9721 for more information

Health and safety programs
As a Prudential HealthCare HMO member you can enjoy programs designed to improve or enhance your health and the health of your family Prudential HealthCare Vitamin Advantage lets you have quality formulated vitamins shipped directly
to your home saving you time and money The Prudential HealthCare Bike Helmet Program makes quality bicycle helmets available to people of all ages even non plan members for as little as 10 Call 1 800 MY HEALTH

Benefits on this page are not part of the FEHB contract
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Prudential HealthCare HMO 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 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

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 1 800 856 0764 or write to 1425 Union Meeting Road P O Box 3013 Blue Bell PA 19422 You may also contact us by fax at 1 215 775 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

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

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

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

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Prudential HealthCare HMO 2000
Section 8 FEHB FACTS continued
What happens When you retire you can usually stay in the FEHB Program Generally you must have been when I retire enrolled in the FEHB Program for the last five years of your Federal service If you do not
meet this requirement you may be eligible for other forms of coverage such as Temporary Continuation of Coverage which is described later in this section

What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and coverage are your unmarried dependent children under age 22 including any foster or step children your
available for my employing or retirement office authorizes coverage for Under certain circumstances you family and me 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 We will keep your medical and claims information confidential Only the following will and 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

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Prudential HealthCare HMO 2000
Section 8 FEHB FACTS continued
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
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 are 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

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Prudential HealthCare HMO 2000
Section 8 FEHB FACTS continued
Your benefits and rates will differ from those under the FEHB Program however you will not have to answer questions about your health and we will not impose a waiting period or
limit your coverage due to pre existing conditions
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan 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

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Prudential HealthCare HMO 2000
Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for services you did not receive billed you twice for the same service or misrepresented any
information do the following Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 1 800 856 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 2000
Notes

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Prudential HealthCare HMO 2000
Notes

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Prudential HealthCare HMO 2000
Summary of Benefits for Prudential HealthCare HMO 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 11
Mental conditions Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per year or 60 days of day treatment
You pay nothing for the first 5 days and 20 for the next 25 days of inpatient treatment or you pay nothing for 10 days and 20 of charges
for next 50 days of day treatment 13
Substance Abuse Covered under mental conditions 14

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 8
Home health care All necessary visits by nurses and health aides You pay nothing 9
Mental conditions Up to 40 outpatient visits for individual counseling per year You pay nothing for first 3 visits and 20 of charges for next 37 visits
all charges thereafter Group counseling visits may be substituted for individual visits on a 3 for 2 basis 13

Substance abuse Covered under mental conditions 14
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 or 25 for urgent care center visits and any charges for services that are not covered by this Plan 12

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 15 copay for a brand name formulary drug and a 25 copay for a non formulary drug 14

Dental care Accidental injury benefit you pay 10 Preventive dental care no current benefit 15
Vision care No current benefit
Out of pocket maximum Copayments are required for a few benefits however after your out of pocket expenses reach a maximum of 500 per Self Only or
1,500 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 5

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2000 Rate Information for
Prudential HealthCare HMO

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

Tulsa Area
Self Only RS1 74.26 24.75 160.89 53.63 87.87 11.14 87.97 11.14
Self and Family RS2 164.35 54.78 356.09 118.69 194.48 24.65 194.48 24.65

Oklahoma City Area
Self Only RR1 65.75 21.91 142.45 47.48 77.80 9.86 77.80 9.86
Self and Family RR2 174.99 58.33 379.15 126.38 207.07 26.25 201.02 32.30

RRD 8104859
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