For changes
in benefits
see page 3
Serving Austin Beaumont Corpus Christi Victoria Houston Gulf Coast areas Lufkin and San Antonio Enrollment in this Plan is limited see page 3 for requirements
Houston Gulf Coast areas Beaumont Lufkin areas
Enrollment code Enrollment code UM1 Self Only ZF1 Self Only
UM2 Self and Family ZF2 Self and Family
Austin Corpus Christi
San Antonio Victoria areas
Enrollment code ZE1 Self Only
ZE2 Self and Family This plan has full accreditation
from the NCQA See the 2000 Guide
for more information on NCQA
Visit the OPM website at http www opm gov insure
and
Visit this Plan's Website at http www txnylcare com
Authorized for distribution by the
UNITED STATES OFFICE OF PERSONNEL MANAGEMENT
RETIREMENT AND INSURANCE SERVICE
RI 73 120
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NYLCare Health Plans of the Gulf Coast Inc 2000
Table of Contents Page
Introduction 2
Plain language 2
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 6
Section 4 What to do if we deny your claim or request for service 7 8
Section 5 Benefits 9 16
Section 6 General exclusions Things we don't cover 17
Section 7 Limitations Rules that affect your benefits 17
Section 8 FEHB FACTS 19
Inspector General Advisory Stop Healthcare Fraud 22
Summary of benefits 23
Premiums 24
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NYLCare Health Plans of the Gulf Coast Inc 2000
Introduction
NYLCare Health Plans of the Gulf Coast Inc
2425 West Loop South Suite 1000
Houston TX 77027 4208
800 833 5318
This brochure describes the benefits you can receive from NYLCare Gulf Coast HMO under its contract CS 1951 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 NYLCare Gulf Coast HMO 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
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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NYLCare Health Plans of the Gulf Coast Inc 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 preventive care such as routine office visits physical exams well baby care and shots as well as treatment
for illness and injury
When you receive services from our providers you will not have to submit claim forms or pay bills However 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 you premiums as low as possible OPM has set a minimum copay of 10 for all primary changes 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 You may ask that a
physician amend a record that is not accurate relevant or complete If the physician does not
amend your record you may add a brief statement to the record
If you are over age 50 all FEHB plans will cover a screening sigmoidoscopy every five years
This screening is for colorectal cancer
Changes to this Plan Under enrollment code UM your share of the non postal premium will increase by 9.9 for Self Only or 10.3 for Self and Family
Under enrollment code ZE your share of the non postal premium will decrease by 1.1
for Self Only and 1.2 for Self and Family
Under enrollment code ZF your share of the non postal premium will decrease by 0.7
for Self Only and 1.0 for Self and Family
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Section 3 How to get benefits
What is this To enroll with us you must live or work in our service area This is where our providers practice Our Plan's service service area is Austin Beaumont Corpus Christi Victoria Houston Gulf Coast areas Lufkin and San
area Antonio
Houston Gulf Coast area
Enrollment code UM1 Self Only
UM2 Self and Family
The Texas counties of Austin Brazoria Chambers Colorado Fort Bend Galveston Grimes Harris Liberty Matagorda Montgomery San Jacinto Walker Waller Washington and Wharton Counties
plus Galveston Island
Austin Corpus Christi Victoria and San Antonio areas
Enrollment code ZE1 Self Only
ZE2 Self and Family
The counties of in the Austin area Bastrop Bell Blanco Brazos Burleson Burnet Fayette Hays Lee Leon Madison Milam Robertson Travis and Williamson Counties in the Corpus
Christi Victoria areas Aransas Calhoun Jackson Jim Wells Kleberg Nueces Refugio San Patricio and Victoria counties and in the San Antonio area Bexar Caldwell Comal Gonzales Guadalupe and
Lavaca Counties
Beaumont area
Enrollment code ZF1 Self Only
ZF2 Self and Family
The Texas counties of Hardin Jasper Jefferson Newton and Orange Counties in the Lufkin area Anderson Angelina Cherokee Houston Nacogdoches Panola Polk Rusk Sabine San Augustine
Shelby Trinity and Tyler Counties
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 a set dollar amount or pay for services coinsurance a set percent of charges Please remember you must pay this amount when you receive
services
After you pay 650 in copayments or coinsurance for one family member or up to 1,500 per family you do not have to make any further payments for certain services for the rest of the year This is called
a catastrophic limit However copayments or coinsurance for your prescription drugs and inpatient mental health 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
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Do I have to You normally won't have to submit claims to us unless you receive emergency services from a provider submit claims 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 The first and most important decision each member must make is the selection of a primary care my health care physician The decision is important since it is through this doctor that all other health services
particularly those of specialists are obtained It is the responsibility of your primary care physician to
obtain any necessary authorizations from the Plan before referring you to a specialist or making
arrangements for hospitalization Services of other providers are covered only when there has been a
referral by the member's primary care physician with the following exceptions a woman may see her
Plan gynecologist for all covered gynecological care Also dental services from a Plan dentist do not
require a referral from the primary care physician except for services relating to the accidental injury
benefits
What do I do if Call us We will help you select a new one my primary
care physician leaves the Plan
What do I do if I Talk to your Plan physician If you need to be hospitalized your primary care physician or specialist need to go into will make the necessary hospital arrangements and supervise your care
the hospital
What do I do if First call our customer service department at 800 833 5318 If you are new to the FEHB Program we I'm in the will arrange for you to receive care If you are currently in the FEHB Program and are switching to us
hospital when I your former plan will pay for the hospital stay until join this Plan
You are discharged not merely moved to an alternative care center or
The day your benefits from your former plan run out or The 92nd day after you became a member of this Plan whichever happens
first
These provisions only apply to the person who is hospitalized
How do I get Your primary care physician will arrange your referral to a specialist specialty care
If you need to see a specialist frequently because of a chronic complex or serious medical condition
your primary care physician will develop a treatment plan that allows you to see your specialist for a
certain number of visits without additional referrals Your primary care physician will use our criteria
when creating your treatment plan The physician may have to get an authorization or approval
beforehand
What do I do if I Your primary care physician will decide what treatment you need If they decide to refer you to a am seeing a specialist ask if you can see your current specialist If your current specialist does not participate with
specialist when us you must receive treatment from a specialist who does Generally we will not pay for you to see a I enroll specialist who does not participate with our Plan
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What do I do if Call your primary care physician who will arrange for you to see another specialist You may receive my specialist services from your current specialist until we can make arrangements for you to see someone else
leaves the Plan
But what if I Please contact us if you believe your condition is chronic or disabling You may be able to continue have a serious seeing your provider for up to 90 days after we notify you that we are terminating our contract with the
illness and my provider unless the termination is for cause If you are in the second or third trimester of pregnancy provider leaves you may continue to see your OB GYN until the end of your postpartum care
the Plan or this You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and Plan leaves the
you enroll in a new FEHB plan Contact the new plan and explain that you have a serious or chronic Program
condition or are in your second or third trimester Your new plan will pay for or provide your care for
up to 90 days after you receive notice that your prior plan is leaving the FEHB Program If you are in
your second or third trimester your new plan will pay for the OB GYN care you receive from your
current provider until the end of your postpartum care
How do you Your physician must get our approval before sending you to a hospital referring you to a specialist or authorize recommending follow up care Before giving approval we consider if the service is medically
medical necessary and if it follows generally accepted medical practice services
How do you We consider a drug device procedure or treatment to be experimental if decide if a There are insufficient outcomes data available from controlled clinical trials published in peerreviewed
service is literature to substantiate its safety and effectiveness for the disease or injury involved or experimental or Approval has not been granted for marketing if required by the FDA or
investigational A recognized national medical or dental society or regulatory agency has determined in writing that it is experimental investigational or for research purposes or
Written protocol s used by the treating facility or the protocols of any other facility studying substantially the same drug device procedure or treatment or the written informed consent used
by the treating facility or by another facility studying the same drug device procedure or treatment
states that it is experimental investigational or for research purposes
Our coverage policy excludes procedures that are experimental or investigational However we have also developed a policy and process for handling issues involving the use of
experimental investigational procedures in terminally ill patients
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Section 4 What to do if we deny your claim or request for service
If we deny services or won't pay your claim you may ask us to reconsider our decision Your request must
1 Be in writing
2 Refer to specific brochure wording in explaining why you believe our decision is wrong and
3 Be made within six months from the date of our initial denial or refusal We may extend this time limit if you show
that you were unable to make a timely request due to reasons beyond your control
We have 30 days from the date we receive your reconsideration request to
1 Maintain our denial in writing
2 Pay the claim
3 Arrange for a health care provider to give you the service or
4 Ask for more information
If we ask your medical provider for more information we will send you a copy of our request We must make a decision
within 30 days after we receive the additional information If we do not receive the requested information within 60 days we
will make our decision based on the information we already have
When may I ask You may ask OPM to review the denial after you ask us to reconsider our initial denial or OPM to review a refusal OPM will determine if we correctly applied the terms of our contract when we denied
denial your claim or request for service
What if I have a Call us at 800 833 5318 and we will expedite our review serious or lifethreatening
condition and you haven't
responded to my request for service
What if you have If we expedite our review due to a serious medical condition and deny your claim we will denied my request inform OPM so that they can give your claim expedited treatment too Alternatively you can
for care and my call OPM's health benefits Division IV at 202 606 0737 between 8 a m and 5 p m Serious or condition is serious life threatening conditions are ones that may cause permanent loss of bodily functions or death if
or life threatening they are not treated as soon as possible
Are there other time You must write to OPM and ask them to review our decision within 90 days after we uphold our limits 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
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What do I send to Your request must be complete or OPM will return it to you You must send the following 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 the Those who have a legal right to file a disputed claim with OPM are 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 mail Send your request for review to Office of Personnel Management Office of Insurance my disputed claim to Programs Contract Division IV P O Box 436 Washington D C 20044
OPM
What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with our upholds the Plan's decision your only recourse is to sue
denial If you decide to sue you must file the suit against OPM in Federal court by December 31 of the
third year after the year in which you received the disputed services or supplies
What laws apply if I Federal law governs your lawsuit benefits and payment of benefits The Federal court will base file a lawsuit 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 the Chapter 89 of title 5 United States Code allows OPM to use the information it collects from you Privacy Act 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
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Section 5 Benefits
Medical and surgical benefits What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and
other Plan providers This includes all necessary office visits you pay a 10 office visit copay but no
additional copay for laboratory tests and X rays nothing for well baby care visits and health assessments
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 15 if after hours or a 10 copay
for visits by nurses and health aides
The following services are included and are subject to the office visit copay unless stated otherwise
Preventive care including well women exams copay waived well baby care examination for the detection of prostate cancer and periodic health assessments copay waived
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 copay waived
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 you pay the office visit copay of 10 for the first maternity visit
copays for subsequent maternity care are waived 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 enrollment in the Plan is terminated during pregnancy
benefits will not be provided after coverage under the Plan has ended Ordinary nursery care of the
newborn child during the covered portion of the mother's hospital confinement for maternity will be
covered under either a Self Only or Self and Family enrollment other care of the infant requiring
definitive treatment will be covered only if the infant is covered under a Self and Family enrollment
Voluntary family planning services you pay 25 for insertion or removal of I U D s Contraceptive diaphragms are covered you pay 25 for the fitting of the diaphragm 10 for the diaphragm itself
you pay 50 copay for insertion and or removal of birth control device implanted under the skin
External breast prosthesis and surgical bras following a mastectomy
Diagnosis and treatment of diseases of the eye
The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart heart lung kidney single lung double lung 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 advanced non Hodgkin's lymphoma advanced
neuroblastoma testicular mediastinal retroperitoneal and ovarian germ cell tumors breast cancer
multiple myeloma and epithelial ovarian cancer 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 the Plan
Women who undergo mastectomies may at their option have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours after the procedure
Dialysis
Orthopedic devices such as braces and foot orthotics
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity
Home health services of nurses and health aides when prescribed by your Plan doctor who will periodically review the program for continuing appropriateness and need IV fluids and medications
for home use are covered The office visit copay is charged only when professional services are
necessary to administer the benefit and
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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Limited benefits Provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and Oral and cleft palate and for medical or surgical procedures occurring within or adjacent to the oral cavity or
maxillofacial sinuses including but not limited to treatment of fractures and excision of tumors and cysts All other surgery 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 Provided to correct a condition resulting from a functional defect or from an injury or surgery that has surgery produced a major effect on the member's appearance and if the condition can reasonably be expected to be
corrected by such surgery
Rehabilitative Rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis therapy Your coverage is limited to services which continue to meet or exceed the treatment goals established for
you For a physically disabled person treatment goals may include maintenance of functioning or
prevention of or slowing of further deterioration you pay a 10 copay for each 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
Durable medical Durable medical equipment such as wheelchairs and hospital beds is covered Durable medical equipment equipment is rented or purchased at the Plan's option The Plan will cover hearing aids and one cleaning
of a hearing aid per year Hearing aids may be replaced once every 4 years unless the member's
condition requires more frequent replacement The repair replacement except for hearing aids or
maintenance of durable medical equipment is not covered You pay nothing
Prosthetic devices Prosthetic devices such as artificial limbs and external lenses following cataract removal is covered for the initial device only you pay nothing Replacements repair and periodic maintenance are excluded
Diabetic supplies Diabetic supplies equipment and education is covered except that syringes needles lancets and test strips are covered under Prescription Drug Benefits you pay a 10 copay
Allergy testing and Allergy testing and treatment including testing materials and allergy serum are provided you pay a 25 treatment copay for each session of testing Allergy serum and the administration of the serum is covered at 50
Sterilizations Sterilizations are provided you pay a 25 copay for tubal ligation or vasectomy procedure
Diagnosis and Diagnosis and treatment of infertility is covered you pay a 25 copay for each testing The following treatment of types of artificial insemination are covered intravaginal insemination IVI intracervical insemination
infertility ICI and intrauterine insemination IUI you pay 50 of charges for each service The cost of donor sperm is not covered Oral fertility drugs are covered under the prescription drug benefit Other assisted
reproductive technology ART procedures such as in vitro fertilization and embryo transfer are not
covered
Cardiac Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is provided rehabilitation for up to 60 visits per condition you pay a 10 copay per visit
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
Podiatric services for routine care except when provided to diabetic patients
Chiropractic services
Homemaker services
Orthopedic shoes unless built into a leg brace
Refractions and eye exercises
Corrective eyeglasses and frames or contact lenses including the fitting of the lenses Fertility drugs other than oral and
Transplants not specified as covered
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Hospital extended care benefits
What is covered The Plan provides a comprehensive range of benefits with no dollar or day limit when you are Hospital care 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 and
Specialized care units such as intensive care or cardiac care units
Extended care The Plan provides a comprehensive range of benefits for up to 60 days per calendar year when full time skilled nursing care is necessary and confinement in a skilled nursing facility is medically appropriate as
determined by a Plan doctor and approved by the Plan You pay nothing per inpatient admission All
necessary services are covered including
Bed board and general nursing care and
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
Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
Limited benefits Hospitalization for certain dental procedures is covered when a Plan doctor determines there is a need for Inpatient dental hospitalization for reasons totally unrelated to the dental procedure the Plan will cover the
procedures hospitalization but not the cost of the professional dental services Conditions for which hospitalization would be covered include hemophilia and heart disease the need for anesthesia by itself is not such a
condition
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care diagnosis detoxification treatment of medical conditions and medical management of withdrawal symptoms acute detoxification
if the Plan doctor determines that outpatient management is not medically appropriate See page 23 for
non medical Substance Abuse Benefits
What is not covered Personal comfort items such as telephone and television and Custodial care rest cures domiciliary or convalescent care
Emergency benefits
What is emergency Emergency care means healthcare services provided in a hospital emergency facility or comparable care facility to evaluate and stabilize medical conditions of a recent onset and severity including but not
limited to severe pain that would lead a prudent layperson possessing an average knowledge of medicine and health to believe his or her condition sickness or injury is of such a nature that failure to get
immediate medical care could result in Placing the patient's health in serious jeopardy
Serious impairment to bodily functions Serious dysfunction of any bodily organ or part
Serious disfigurement or In the case of a pregnant woman serious jeopardy to the health of the fetus
Heart attacks cardiovascular accidents poisoning loss of consciousness or breathing convulsions severe bleeding and broken bones are examples of medical emergencies for which emergency care
would be covered
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Emergency care Emergency care includes the following services services An initial medical screening examination by the facility providing the emergency care or other
evaluation required by state or federal law that is necessary to determine whether an emergency
medical condition exists
Services for the treatment and stabilization of an emergency condition and
Poststabilization care originating in a hospital emergency room or comparable facility if approved by us provided that we must approve or deny coverage within one hour of a request for approval by the
treating physician or the hospital emergency room
Emergencies within If you are in an emergency situation please call your primary care doctor In extreme emergencies if you the service area 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
unless it was not reasonable to do so 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 care services to the extent the services would have been covered if received from Plan providers
You pay A 15 copay per urgent care center visit 15 per visit to a physician's office after normal business hours a 75 copay per emergency care center visit for emergency care services that are covered benefits of this
Plan If the emergency results in admission to a hospital the emergency care copay is waived
Emergencies outside Benefits are available for any medically necessary health service that is immediately required because of the service area 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 A 15 copay per urgent care center visit 15 per visit to a physician's office after normal business hours a 75 copay per emergency room visit for emergency care services that are covered benefits of this Plan
If the emergency results in admission to a hospital the emergency care copay is waived
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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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 and
Poststabilization care originating in a hospital emergency room or comparable facility if approved by us provided that we must approve or deny coverage within one hour of a request for approval by the
treating physician or the hospital emergency room
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 departing the Service Area and
Medical and hospital costs resulting from a normal full term delivery of a baby outside the Service Area
Filing claims for nonPlan With your authorization the Plan will pay benefits directly to the providers of your emergency care upon providers 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 the Plan along with an
explanation of the services and the identification information from your ID card Payment will be sent to
you or the provider if you did not pay the bill unless the claim is denied If it is denied you will receive
notice of the decision including the reasons for the denial and the provisions of the contract on which
denial was based If you disagree with the Plan's decision you may request reconsideration in accordance
with the disputed claims procedure
Mental Conditions Substance Abuse Benefits
Mental conditions What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis and
treatment of acute psychiatric conditions including treatment of mental illness or disorders
Diagnostic evaluation Psychological testing
Psychiatric treatment including individual and group therapy and
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 a 25 copay for each covered visit all charges thereafter
Inpatient care Up to 30 days of hospitalization or up to 60 days of daycare each calendar year you pay nothing for first 30 days all charges thereafter
Serious mental Up to 60 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year illness you pay a 10 copay for each covered visit all charges thereafter
Outpatient care
Inpatient care Up to 45 days of hospitalization each calendar year you pay nothing for the first 45 days all charges thereafter
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 and
Psychological testing when not medically necessary to determine the appropriate treatment of a short term
psychiatric condition
Substance abuse This Plan provides medical and hospital services such as acute detoxification services for the medical What is covered 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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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NYLCare Health Plans of the Gulf Coast Inc 2000
Outpatient care All necessary outpatient visits to Plan providers for treatment you pay a 10 copay for each covered visit
Inpatient care All necessary care you pay nothing
What is not covered Treatment that is not authorized by a Plan doctor
Prescription Drug Benefits
What is covered Prescription drugs prescribed by a Plan or referral doctor and obtained from a Plan pharmacy will be dispensed for up to a 30 day supply or 100 unit supply whichever is less You pay a 5 copay for generic
drugs or a 10 copay for name brand drugs per prescription unit or refill
Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary The
formulary is developed by the Plan's Pharmacy and Therapeutic Committee The Committee establishes a
list of preferred drugs which are evaluated based on therapeutic value and cost The list of preferred drugs
is periodically reviewed and updated The Committee uses various outside resources in its review process
which includes the Food and Drug Administration Non formulary drugs will be covered when prescribed
by a Plan doctor
You pay up to a 25 copay per prescription unit or refill for drugs not on the Plan's drug formulary
Prescription drugs obtained through the Plan's Home Delivery Pharmacy Service will be dispensed for up
to a 90 day supply you pay a 5 copay for generic drugs or a 10 copay for name brand drugs or a 25
copay for drugs not on the Plan's drug formulary per prescription unit or refill Injectables except insulin
aerosol inhalers and inhalant solutions are covered only when obtained through the Home Delivery
Pharmacy Service
Drugs purchased as a result of a medical emergency that occurs outside the Plan's service area will be
reimbursed for up to a 10 day supply minus the applicable copay
Covered medications and accessories include
Drugs for which a prescription is required by Federal law
Oral and injectable contraceptive drugs
Smoking cessation drugs and medication including nicotine patches benefit is limited to 185 lifetime maximum
Disposable needles and syringes needed to inject covered prescribed medication including insulin Intravenous fluids and medications for home use and
Oral fertility drugs
Limited benefits Drugs to treat sexual dysfunction are covered Contact the Plan for dose limits You pay a 25 copay up to the dose limit and all charges thereafter
What is not covered Drugs available without a prescription or for which there is a non prescription equivalent available Drugs obtained at a non Plan pharmacy except for out of area emergencies
Vitamins and nutritional substances that can be purchased without a prescription
Medical supplies such as dressings and antiseptics Drugs for cosmetic purposes Drugs to enhance athletic performance
Implanted time release medications except Norplant
Injectables aerosol inhalers and inhalant solutions except when purchased through the Home Delivery Pharmacy Service
Fertility drugs other than oral and
Topical fluoride
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Other Benefits
Dental care Accidental injury Restorative services and supplies necessary to promptly repair but not replace sound natural teeth The
benefit need for these services must directly result from an accidental injury not biting or chewing Treatment must be initiated within 72 hours of the accident you pay nothing
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 of this Plan The cost of the benefits described on this page is not included in the FEHB
premium and any charges for these services do not count toward any FEHB deductibles or out of pocket maximums These benefits
are not subject to the FEHB disputed claims procedure
Vision services NYLCare Health Plan members are eligible to receive vision care at a substantial discount This program includes a comprehensive eye examination frames and corrective lenses eyeglasses or contact lenses To
be covered the exam must be provided by a NYLCare Health Plans participating optometrist The
prescription for lenses or contacts must be filled by a participating NYLCare Health Plans optometrist
SERVICE AMOUNT YOU PAY
Exams and Frames
Eye Examination 3.00
Frames Standard 28.00
Premium 33.00
LENSES Per Pair
Single Vision 29.00
Bifocal 49.00
Trifocal 55.00
Lenticular 75.50
Progressive 101.50
CONTACT LENS SERVICE Per Pair
Benefit includes fitting lenses and follow up care
STANDARD LENSES PREMIUM LENSES
Daily wear hard and soft Daily wear hard and soft
Extended wear soft Extended wear soft
Gas Permeable Opaque soft extended wear lenses
Toric
Disposable 4 6 packs
Co payments may vary when a Medical Group is assigned as a Primary Care Physician
Dental services NYLCare Health Plan offers affordable and guaranteed fees for dental care with more than seventy dentists in the network The dental services offer no pre existing condition limitations no deductibles and no claim
forms for your convenience
Dental Services Diagnostic Dentistry to include initial oral exam periodic No Copayment Amount You Pay oral exam treatment plan and consultations
General Specialty Dental Services Various Copayments
Orthodontics for adults and children
Initial Consultation No Copayment
Diagnostic Records and Consultation Fees 120 Copayment
including orthodontic X rays
Balance of Orthodontic Treatment for Standard 1900 Copayment
2 year case including retention beyond two years
As provided by a General Dentist
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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NYLCare Health Plans of the Gulf Coast Inc 2000
Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not cover it
unless your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition
We do not cover the following
Services drugs or supplies that are not medically necessary
Services not required according to accepted standards of medical dental or psychiatric practice
Care by non Plan providers except for authorized referrals or emergencies see Emergency Benefits
Experimental or investigational procedures treatments drugs or devices
Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered if the fetus were carried to term or when the pregnancy is the result of an act of rape or incest
Procedures services drugs and supplies related to sex transformations
Services or supplies you receive from a provider or facility barred from the FEHB Program and
Expenses you incurred while you were not enrolled in this Plan
Section 7 Limitations Rules that affect your benefits
Medicare Tell us if you or a family member is enrolled in Medicare Part A or B Medicare will determine who is responsible for paying for medical services and we will coordinate the payments On occasion you
may need to file a Medicare claim form
If you are eligible for Medicare you may enroll in a Medicare Choice plan and also remain enrolled
with us
If you are an annuitant or former spouse you can suspend your FEHB coverage and enroll in a
Medicare Choice plan when one is available in your area For information on suspending your FEHB
enrollment and changing to a Medicare Choice plan contact your retirement office If you later want
to re enroll in the FEHB Program generally you may do so only at the next Open Season
If you involuntarily lose coverage or move out of the Medicare Choice service area you may re enroll
in the FEHB Program at any time
If you do not have Medicare Part A or B you can still be covered under the FEHB Program and your
benefits will not be reduced We cannot require you to enroll in Medicare
For information on Medicare Choice plans contact your local Social Security Administration SSA
office or request it from SSA at 1 800 638 6833
For information on the Medicare Choice plan offered by NYLCare Gulf Coast please call
800 659 6505
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NYLCare Health Plans of the Gulf Coast Inc 2000
Other group When anyone has coverage with us and with another group health plan it is called double coverage insurance You must tell us if you or a family member has double coverage You must also send us documents
coverage about other insurance if we ask for them
When you have double coverage one plan is the primary payer it pays benefits first The other plan is
secondary it pays benefits next We decide which insurance is primary according to the National
Association of Insurance Commissioners Guidelines
If we pay second we will determine what the reasonable charge for the benefit should be After the
first plan pays we will pay either what is left of the reasonable charge or our regular benefit whichever
is less We will not pay more than the reasonable charge If we are the secondary payer we may be
entitled to receive payment from your primary plan
We will always provide you with the benefits described in this brochure Remember even if you do
not file a claim with your other plan you must still tell us that you have double coverage
Circumstances Under certain extraordinary circumstances we may have to delay your services or be unable to provide beyond our them In that case we will make all reasonable efforts to provide you with necessary care
control
When others When you receive money to compensate you for medical or hospital care for injuries or illness that are responsible another person caused you must reimburse us for whatever services we paid for We will cover the
for injuries cost of treatment that exceeds the amount you received in the settlement If you do not seek damages you must agree to let us try This is called subrogation If you need more information contact us for
our subrogation procedures
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this Plan cover you we are the
primary payer See your TRICARE Health Benefits Advisor if you have questions about TRICARE
coverage
Workers We do not cover services that compensation
You need because of a workplace related disease or injury that the Office of Workers Compensation Programs OWCP or a similar Federal or State agency determine they must
provide
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment we will provide
your benefits
Medicaid We pay first if both Medicaid and this Plan cover you
Other We do not cover services and supplies that a local State or Federal Government agency directly or Government indirectly pays for
Agencies
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NYLCare Health Plans of the Gulf Coast Inc 2000
Section 8 FEHB FACTS
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the information about right to information about your health plan its networks providers and facilities You can also
your HMO find out about care management which includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational
OPM's website www opm gov lists the specific types of information that we must make available to you
If you want specific information about us call 800 833 5318 or write to NYLCare Gulf Coast 2425 West Loop South Suite 1000 Houston Texas 77027 You may also contact us by fax at
713 354 7014 or visit our website at www txnylcare com
Where do I get Your employing or retirement office can answer your questions and give you a Guide to Federal information about Employees Health Benefits Plans brochures for other plans and other materials you need to
enrolling in the 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 When you retire you can usually stay in the FEHB Program Generally you must have been I retire enrolled in the FEHB Program for the last five years of your Federal service If you do not meet
this requirement you may be eligible for other forms of coverage such as Temporary Continuation of Coverage which is described later in this section
What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and your coverage are 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 may family and me also get coverage for a disabled child 22 years of age or older who is incapable of self support
If you have a Self Only enrollment you may change to a Self and Family enrollment if you marry give birth or add a child to your family You may change your enrollment 31 days before
to 60 days after you give birth or add the child to your family The benefits and premiums for your Self and Family enrollment begin on the first day of the pay period in which the child is
born or becomes an eligible family member
Your employing or retirement office will not notify you when a family member is no longer eligible to receive health benefits nor will we Please tell us immediately when you add or
remove family members from your coverage for any reason including divorce
If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled in another FEHB plan
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NYLCare Health Plans of the Gulf Coast Inc 2000
Are my medical and We will keep your medical and claims information confidential Only the following will have claims records access to it
confidential OPM this Plan and subcontractors when they administer this contract
This plan and appropriate third parties such as other insurance plans and the Office of Workers Compensation Programs OWCP when coordinating benefit payments and
subrogating claims
Law enforcement officials when investigating and or prosecuting alleged civil or criminal actions
OPM and the General Accounting Office when conducting audits
Individuals involved in bona fide medical research or education that does not disclose your identity or
OPM when reviewing a disputed claim or defending litigation about a claim
Information for new members
Identification 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 If you enrolled through Employee
Express you can request a confirmation letter from their Help line at 912 757 3030
What if I paid a Your old plan's deductible continues until our coverage begins deductible under
my old plan
Pre existing We will not refuse to cover the treatment of a condition that you or a family member had before conditions you enrolled in this Plan solely because you had the condition before you enrolled
When you lose benefits
What happens if You will receive an additional 31 days of coverage for no additional premium when my enrollment in
this Plan ends Your enrollment ends unless you cancel your enrollment or You are a family member no longer eligible for coverage
You may be eligible for former spouse coverage or Temporary Continuation of Coverage
What is former If you are divorced from a Federal employee or annuitant you may not continue to get benefits spouse coverage under your spouse's enrollment But you may be eligible for your own FEHB coverage under
the spouse equity law If you are recently divorced or are anticipating a divorce contact your exspouse's
employing or retirement office to get more information about your coverage choices
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NYLCare Health Plans of the Gulf Coast Inc 2000
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible for TCC For
example you can receive TCC if you are not able to continue your FEHB enrollment after you
retire You may not elect TCC if you are fired from your Federal job due to gross misconduct
Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees
Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse Enrollees
from your employing or retirement office
Key points about TCC
You can pick a new plan
If you leave Federal service you can receive TCC for up to 18 months after you separate
If you no longer qualify as a family member you can receive TCC for up to 36 months Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32 nd day after your regular coverage ends even if several months have
passed
You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll in If you are leave Federal service your employing office will notify you of your right to enroll TCC under TCC You must enroll within 60 days of leaving or receiving this notice whichever is
later
Children You must notify your employing or retirement office within 60 days after your
child is no longer an eligible family member That office will send you information about
enrolling in TCC You must enroll your child within 60 days after they become eligible for
TCC or receive this notice whichever is later
Former spouses You or your former spouse must notify your employing or retirement office
within 60 days of one of these qualifying events
Divorce Loss of spouse equity coverage within 36 months after the divorce
Your employing or retirement office will then send your former spouse information about
enrolling in TCC Your former spouse must enroll within 60 days after the event which
qualifies them for coverage or receiving the information whichever is later
Note Your child or former spouse loses TCC eligibility unless you or your former spouse
notify your employing or retirement office within the 60 day deadline
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NYLCare Health Plans of the Gulf Coast Inc 2000
How can I convert You may convert to an individual policy if to individual
coverage Your coverage under TCC or the spouse equity law ends If you canceled your coverage or did not pay your premium you cannot convert
You decided not to receive coverage under TCC or the spouse equity law or
You are not eligible for coverage under TCC or the spouse equity law
If you leave Federal service your employing office will notify you if individual coverage is
available You must apply in writing to us within 31 days after you receive this notice
However if you are a family member who is losing coverage the employing or retirement office
will not notify you You must apply in writing to us within 31 days after you are no longer
eligible for coverage
Your benefits and rates will differ from those under the FEHB Program however you will not
have to answer questions about your health and we will not impose a waiting period or limit
your coverage due to pre existing conditions
How can I get a If you leave the FEHB Program we will give you a Certificate of Group Health Plan Coverage Certificate of that indicates how long you have been enrolled with us You can use this certificate when
Group Health getting health insurance or other health care coverage You must arrange for the other coverage Plan 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 800 833 5318 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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NYLCare Health Plans of the Gulf Coast Inc 2000
Summary of benefits for NYLCare Health Plans of the Gulf Coast Inc 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 summarized 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 11 Extended care All necessary services for up to 60 days per year You pay nothing 11
Mental conditions Diagnosis and treatment of acute psychiatric conditions for up to 30 days of inpatient care per year You pay nothing 13
Serious mental Diagnosis and treatment of Serious Mental Illness for up to 45 days of illness inpatient care per year You pay nothing 13
Substance abuse All necessary care You pay nothing 13 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 for office visit or for house calls by a doctor copayment waived for preventive care 9
Home health care All necessary visits by nurses and health aides You pay a 10 copay per visit 9
Mental conditions Up to 20 outpatient visits per year You pay a 25 copay per visit 13 14 Serious mental Up to 60 outpatient visits per year You pay a 10 copay per visit 13
illness Substance abuse All necessary outpatient visits You pay a 10 copay per visit 13 14
Emergency care Reasonable charges by a Plan doctor for up to a 30 day supply may be obtained at a Plan pharmacy you pay a 75 copay to the hospital for
each emergency room visit 15 for urgent care center visit and any charges for services that are not covered benefits of this Plan 12 13
Prescription Drugs prescribed by a Plan doctor for up to a 30 day supply may be drugs obtained at a Plan pharmacy you pay a 5 copay for generic drugs a
10 copay for name brand drugs or a 25 copay for non formulary drugs per prescription unit or refill For up to a 90 day supply of
drugs obtained from Home Delivery Pharmacy Service you pay a 5 copay for generic drugs or 10 for name brand drugs or a 25 copay
for non formulary drugs per prescription unit or refill 14
Dental care Accidental injury benefit You pay nothing 15 16 Vision care No current benefit
Out of pocket limit Copayments are required for a few benefits however after your outof pocket expenses reach a maximum of 650 per Self only and
1,500 per Self and family enrollment per calendar year covered benefits will be provided at 100 This copay maximum does not
include costs of prescription drugs and inpatient care of mental conditions 4
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2000 Rate Information for
NYLCare Health Plans of the Gulf Coast
Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the FEHB Guide for that category or contact the agency that maintains your health benefits enrollment
Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates referred to as Category A rates and Category B rates will apply for certain career employees If you are a career postal employee but not a member
of a special postal employment class refer to the category definitions in The Guide to Federal Employees Health Benefits Plans for
United States Postal Service Employees RI 70 2 to determine which rate applies to you
Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes or associate
members of any postal employee organization Such persons not subject to postal rates must refer to the applicable Guide to Federal
Employees Health Benefits Plans
Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Code Gov't Your Gov't Your USPS Your USPS Your
Enrollment Share Share Share Share Share Share Share Share
Houston area Self Only
UM1 74.87 24.96 162.23 54.07 88.60 11.23 88.60 11.23
Self and Family UM2 175.97 83.62 381.27 181.18 207.74 51.85 201.02 58.57
Beaumont Lufkin areas and Self Only ZF1 62.88 20.96 136.24 45.41 74.41 9.43 74.41 9.43
Self and Family ZF2 140.22 46.74 303.81 101.27 165.93 21.03 165.93 21.03
Austin Corpus Christi San Antonio Victoria areas Self Only
ZE1 50.04 16.68 108.42 36.14 59.21 7.51 59.21 7.51
Self and Family ZE2 130.22 43.40 282.14 94.04 154.09 19.53 154.09 19.53
24 25