Pages 1--24 from 5891pruD1R2_Richmond

For changes
in benefits page 3
see

Serving Central Virginia including the Tri Cities Area

Enrollment in this Plan is limited see page 4 for requirements
Enrollment code
V61 Self only
V62 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
our website at http www aetnaushc com pruhealthcare

Authorized for distribution by the
UNITED STATES OFFICE OF PERSONNEL MANAGEMENT
RETIREMENT AND INSURANCE SERVICE
RI 73 132 1
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Prudential HealthCare HMO Richmond 2000
Table of Contents Page
Introduction 1
Plain language 1
How to use this brochure 2
Section 1 Health Maintenance Organizations 3
Section 2 How we change for 2000 3
Section 3 How to get benefits 4
Section 4 What to do if we deny your claim or request for service 6
Section 5 Benefits 7
Section 6 General exclusions Things we don't cover 16
Section 7 Limitations Rules that affect your benefits 16
Section 8 FEHB FACTS 17
Inspector General Advisory Stop Healthcare Fraud 20
Summary of benefits Inside Back Cover
Premiums Back Cover 2
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Prudential HealthCare HMO Richmond 2000
Introduction

Prudential Health Care Plan Inc Prudential HealthCare HMO Richmond 1425 Union Meeting Road P O Box 3013 Blue Bell PA 19422
This brochure describes the benefits you can receive from Prudential HealthCare HMO Richmond under its contract CS 1941 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 Richmond as this Plan throughout this brochure even though in other legal documents you will see a plan referred to as a carrier

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

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

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

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

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

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

Changes to this Your share of the premium will increase by 33.6 for Self Only or 70.1 for Self and Plan Family
Our prescription drug copay structure now includes a 25 non formulary copay See page 13
We expand coverage for serious mental illness See page 12
We include coverage for clinical trials See page 8
We increased diabetic coverage See page 8
We offer standing referrals for certain conditions See page 5

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Prudential HealthCare HMO Richmond 2000
Section 3 How to get benefits
What is this To enroll with us you must live in our service area This is where our providers practice Plan's service Our service area is The cities of Richmond Colonial Heights Hopewell Petersburg and

area Williamsburg and the following counties in the Commonwealth of Virginia Amelia Charles City Chesterfield Dinwiddie Goochland Henrico Hanover James City King William
King and Queen Louisa New Kent Nottoway Prince George and Powhatan

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 You must share the cost of some services This is called either a copayment a set dollar I pay for amount or coinsurance a set percentage of charges Please remember you must pay this
services amount when you receive services
After you pay 1,500 in copayments or coinsurance for one family member or 3,000 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 HealthCare HMO Richmond is a member company of Aetna US Healthcare my health We are the first Health Maintenance Organization to be formed in Central Virginia
Prudential HealthCare HMO Richmond has provided services to its members since care December 1 1982

Prudential HealthCare provides comprehensive care to you and members of your family as well as the convenience of one stop health care with lab X ray minor surgery and a
wide range of primary care specialties available in convenient locations
Prudential HealthCare HMO Richmond is a mixed model HMO with medical care provided by The Medical Group as well as a network of individual doctors located
throughout the service area The Medical Group is equipped to deliver comprehensive medical care in convenient facilities where the Prudential HealthCare members can have
virtually all their medical needs satisfied The expanded doctor network provides greater convenience and additional choices for all members The member's primary care physician
coordinates all care
You will need to let us know which primary care physician you select for each member of the family If you need help in choosing a physician please call us at 800 856 0764 You
may change your choice by calling us before the 15th of the month for the change to be effective the following month Requests received after the 15th will be effective on the
month following the next month
You must contact our vendor at 800 647 2220 for all mental health and substance abuse services They will authorize and determine the appropriate number of visits You do not
need a referral from your doctor

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Prudential HealthCare HMO Richmond 2000
Section 3 How to get benefits continued
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 specialist will make the necessary hospital arrangements and supervise your care
into the Outpatient surgical services will be performed at a participating ambulatory surgical center hospital
outpatient center or if medically necessary at a participating hospital Contracted outpatient surgical centers will be used wherever possible

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 Program we will arrange for you to receive care If you are currently in the FEHB Program
hospital when and are switching to us your former plan will pay for the hospital stay until I join this
You are discharged not merely moved to an alternative care center or Plan 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 All follow up care specialty care must be provided or authorized by your primary care physician Do not go to the specialist
unless your primary care physician has arranged for and we have issued an authorization for the referral in advance

You may see a participating obstetrician or gynecologist without a referral or call our vendor for mental health and substance abuse services without a referral from your
physician
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

In certain circumstances your primary care physician may issue a standing referral to a participating specialist for special conditions for a specified period of time Special
conditions means a condition or disease that is 1 life threatening degenerative or disabling and 2 requires specialized medical care over a prolonged period of time Your
primary care physician may also issue a standing referral to a participating board certified specialist in pain management or a participating oncologist for cancer pain Your plan
physician will obtain an authorization from us prior to making these standing referrals
What do I do Your primary care physician will decide what treatment you need If they decide to refer if I am seeing a you to a specialist ask if you can see your current specialist If your current specialist does

specialist when not participate with us you must receive treatment from a specialist who does Generally I enroll we will not pay for you to see a specialist who does not participate with our Plan

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

You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and you enroll in a new FEHB plan Contact the new plan and explain that you
have a serious or chronic condition or are in your second or third trimester Your new plan will pay for or provide your care for up to 90 days after you receive notice that your prior
plan is leaving the FEHB Program If you are in your second or third trimester your new plan will pay for the OB GYN care you receive from your current provider until the end of
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Prudential HealthCare HMO Richmond 2000
Section 3 How to get benefits continued
How do you authorize Your Plan physician must get our approval before sending you to a hospital referring you to medical services a specialist or recommending follow up care Before giving approval we consider if the
service is medically necessary and if it follows generally accepted medical practice
How do you decide We do not cover procedures services or supplies that are experimental or investigational In if a service is order to determine whether or not a procedure service or supply is experimental or

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

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

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

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

If we ask your medical provider for more information we will send you a copy of our request We must make a decision within 30 days after we receive the additional information If we do not receive the requested information within 60 days
we will make our decision based on the information we already have
When may I ask You may ask OPM to review the denial after you ask us to reconsider our initial denial or OPM to review refusal OPM will determine if we correctly applied the terms of our contract when we

a denial denied your claim or request for service
What if I have a serious Call us at 1 800 856 0764 and we will expedite our review or life threatening

condition and you haven't responded to
my request for service
What if you have If we expedite your review due to a serious medical condition and deny your claim we will denied my request inform OPM so that they can give your claim expedited treatment too Alternatively you

for care and my can call OPM's health benefits Division III at 202 606 0755 between 8 a m and 5 p m condition is serious Serious or life threatening conditions are ones that may cause permanent loss of bodily
functions or death if they are not treated as soon as possible or life threatening

Are there other You must write to OPM and ask them to review our decision within 90 days after we uphold time limits our initial denial or refusal of service You may also ask OPM to review your claim if

1 We do not answer your request within 30 days In this case OPM must receive your request within 120 days of the date you asked us to reconsider your claim
2 You provided us with additional information we asked for and we did not answer within 30 days In this case OPM must receive your request within 120 days of the date we
asked you for additional information
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Prudential HealthCare HMO Richmond 2000
Section 4 What to do if we deny your claim or request for service continued
What do I Your request must be complete or OPM will return it to you You must send the following send to OPM information

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

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

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

Plan's denial If you decide to sue you must file the suit against OPM in Federal court by December 31
of the third year after the year in which you received the disputed services or supplies

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

Section 5 Medical and Surgical Benefits
What is covered A comprehensive range of preventive diagnostic and treatment services is provided by Plan doctors and other Plan providers This includes all necessary office visits you pay a 10
office visit copay but no additional copay for laboratory tests and X rays Within the service area house calls will be provided if in the judgment of the Plan doctor such care is
necessary and appropriate you pay nothing for a doctor's house call or for home 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 vision and hearing screening for children through age 17 well baby care and periodic check ups and routine gynecological exams

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 7 9
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Prudential HealthCare HMO Richmond 2000
Section 5 Medical and Surgical Benefits continued
What is covered Sigmoidoscopy screening for colorectal cancer every five years for those age 50 and above continued 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 and above one mammogram every year In
addition to routine screening mammograms are covered when prescribed by the doctor as medically necessary to diagnosis or treat your illness
Routine immunizations and boosters Consultations by specialists
Diagnostic procedures such as laboratory tests and X rays no copay applies Pap smears including the annual testing performed by any FDA approved gynecologic
cytology screening technologies Complete obstetrical maternity care for all covered females including prenatal
delivery and postnatal care by a Plan doctor Copays are waived for pre and postnatal care 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 mothers hospital confinement for
maternity will be covered under either Self Only or Self and Family enrollment other care of an infant who requires definitive treatment will be covered only if the infant is
covered under a Self and Family enrollment Voluntary sterilization and family planning services
Diagnosis and treatment of diseases of the eye Allergy testing and treatment including testing and treatment materials such as allergy
serum The insertion of internal prosthetic devices such as pacemakers and artificial joints
Cornea heart lung single and double heart lung intestinal pancreas kidney and liver transplants allogeneic donor bone marrow transplants autologous bone marrow
transplants autologous stem cell and peripheral stem cell support for the following conditions acute lymphocytic or non lymphocytic leukemia advanced Hodgkin's
lymphoma advanced non Hodgkin's lymphoma advanced neuroblastoma breast cancer multiple myeloma epithelial ovarian cancer and testicular mediastinal retroperitoneal
and ovarian germ cell tumors Transplants are covered when approved by the Medical Director Related medical and hospital expenses of the donor are covered when the
recipient is covered by this Plan Patients who undergo mastectomies may at their option have this procedure performed
on an inpatient basis and remain in the hospital up to 48 hours after the procedure Dialysis
Chemotherapy radiation therapy and inhalation therapy Surgical treatment of morbid obesity
Oxygen and rental of equipment for use of oxygen Implanted time released medications such as Norplant you pay the office visit copay
For Norplant and other internally implanted time release medication there is no charge when the device is implanted during a covered hospitalization There will be no refund of
any portion the copay if the implanted time released medication is removed before the end of its expected life
Disposable needles and syringes needed to inject covered prescribed medications Injectable drugs other than insulin insulin is covered under the Prescription Drug Benefits
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 Chiropractic services
Orthopedic devices such as braces Prosthetic devices such as artificial limbs breast prostheses and surgical bras as well as
their replacement and lenses following cataract removal Initial eyeglasses or lenses for the replacement for loss of the natural lens are also covered
Diabetes equipment supplies outpatient self management training and education which shall be provided by a certified registered or licensed health care professional including
medical nutritional therapy for the treatment of insulin dependent diabetes insulin using diabetes gestational diabetes and non insulin using diabetes
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers
Coverage for patient costs incurred during participation in clinical trials for treatment studies on cancer including ovarian cancer trials Patient costs means the cost of a
medically necessary health care service that is incurred as a result of the treatment being provided to the member for purposes of a clinical trial Patient cost does not include the

8 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 10
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Prudential HealthCare HMO Richmond 2000
Section 5 Medical and Surgical Benefits continued
cost of non health care services that a patient may be required to receive as a result of the treatment being provided for purposes of a clinical trial costs associated with
managing the research associated with the clinical trial or the cost of the investigational drug or device The clinical trial or study must meet eligibility requirements of the Plan
and the Commonwealth of Virginia to be included for coverage under this benefit Please contact us at 800 856 0764 for complete details

Coverage for biologically based mental illness is covered as any other illness Biologically based mental illness is defined as any mental or nervous condition caused
by a biological disorder of the brain that results in a clinically significant syndrome that substantially limits the person's functioning The diagnoses that are defined as
biologically based in adults and children are schizophrenia schizoaffective disorder bipolar disorder major depressive disorder panic disorder obsessive compulsive
disorder attention deficit hyperactivity disorder autism and drug and alcohol addiction
Limited benefits Oral and maxillofacial surgery is provided for non dental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or
surgical procedures occurring within or adjacent to the oral cavity or sinuses including but not limited to treatment of fractures and excision of tumors 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 a congenital and or functional defect or from an injury or surgery that has produced a major effect on
the member's appearance and if the condition can reasonably be expected to be corrected by such surgery A patient and her attending physician may decide whether to have breast
reconstruction surgery following a mastectomy and whether surgery on the other breast is needed to produce a symmetrical appearance

Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis for up to 90 calendar days if significant improvement can be
expected within that period you pay a 10 copay per outpatient session Speech therapy is limited to treatment of certain speech impairments of an 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 Therapy for learning disabilities is
not covered
Durable medical equipment such as wheelchairs and hospital beds are covered up to a maximum benefit of 1,000 per calendar year Coverage includes replacement repairs and
maintenance of durable medical equipment not provided for under a manufacturer's warranty or purchase agreement up to the 1000 limit

Diagnosis and treatment of infertility is covered you pay 50 of charges The following types of artificial insemination are covered intravaginal insemination IVI intracervical
insemination ICI and intrauterine insemination IUI you pay 50 of the charges cost of donor sperm is not covered Fertility drugs are covered Other assisted reproductive
technology ART such as in vitro fertilization and embryo transfer are not covered
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is provided at a Plan facility you pay nothing

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

What is not covered Physical examinations that are not necessary for medical reasons such as those required for obtaining or continuing employment or insurance attending school or camp or travel
Reversal of voluntary surgically induced sterility Surgery primarily for cosmetic purposes
Transplants not listed as covered
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 9 11
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Prudential HealthCare HMO Richmond 2000
Section 5 Medical and Surgical Benefits continued
Hearing aids exams to determine the need for hearing aids or the need to adjust them Cochlear devices
Homemaker services Long term rehabilitative therapy
Eye exercises and eyeglasses contact lenses or the fitting of contact lenses except initial eyeglasses or lenses to replace the loss of the natural lens are covered refraction's
including lens prescriptions Blood and blood derivatives not replaced by or for the patient
Foot orthotics Any eye surgery solely for the purpose of correcting refractive defects of the eye such as
nearsightedness myopia farsightedness hyperopia and astigmatism

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

Bed board and general nursing care Drugs biologicals supplies and equipment ordinarily provided or arranged by the
skilled nursing facility when prescribed by a Plan doctor
Hospice Care Supportive and palliative care for a terminally ill member is covered in the home or hospice facility Services include inpatient and outpatient care and family counseling these services
are provided under the direction of a Plan doctor who certifies that the patient is in the terminal stages of illness with a life expectancy of approximately six months or less Each
person is entitled to a 7,400 maximum per period of care plus 200 for family counseling within three months of the death of the patient

Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor You pay a 25 copayment per trip for these services
Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines procedures there is a need for hospitalization for reasons totally unrelated to the dental procedure the
Plan will cover the hospitalization but not the cost of the professional dental services Conditions for which hospitalization would be covered include hemophilia and heart
disease the need for anesthesia by itself is not such a condition
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care
detoxification diagnosis treatment of medical conditions and medical management of withdrawal symptoms acute detoxification if the Plan doctor determines that outpatient management

is not medically appropriate See page 13 for non medical Substance Abuse Benefits

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

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Prudential HealthCare HMO Richmond 2000
Section 5 Emergency Benefits
What is a A medical emergency is the sudden and unexpected onset of a condition or an injury that medical emergency you believe endangers your life or could result in serious injury or disability and requires
immediate medical or surgical care Some problems are emergencies because if not treated promptly they might become more serious examples include deep cuts and broken bones
Others are emergencies because they are potentially life threatening such as heart attacks strokes poisonings gunshot wounds or sudden inability to breathe There are many other
acute conditions that the Plan may determine are medical emergencies what they all have in common is the need for quick action

Emergencies within If you are in an emergency situation please call your primary care 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 the Plan
You or a family member must notify the Plan within 48 hours unless it was not reasonably possible to do so It is your responsibility to ensure that the Plan has been timely notified

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

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

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

Plan pays Reasonable charges for emergency care services to the extent the services would have been covered if received from Plan providers
You pay 50 per hospital emergency room visit 10 per urgent care center visit for emergency services that are covered benefits of this Plan Urgent care services rendered outside the
service area must be coordinated through the Prudential National Service Hotline in order for the 10 copay to apply If the emergency results in an admission to a hospital the
emergency room copay 50 is waived
What is covered Emergency care at a doctor's office or an urgent care center Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service approved by the Plan You pay 25 per ambulance trip
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

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Prudential HealthCare HMO Richmond 2000
Section 5 Emergency Benefits continued
Medical and hospital costs resulting from a normal full term delivery of a baby outside the service area

Filing claims for With your authorization the Plan will pay benefits directly to the providers of your non Plan providers emergency care upon receipt of their claims Physician claims should be submitted on the
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 described on page 6
Portability If you are away from home and required medical care other than routine physicals Reciprocity immunizations and non emergency maternity care you can access a network facility in the
area you are visiting You will receive this care at a maximum benefit 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 at home to obtain permission for out of area care In life threatening emergencies we recommend that you seek appropriate treatment
immediately However you or a family member must notify the Plan or your primary care doctor within 48 hours concerning the emergency care your 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 doctor
This toll free number is also located on the back of your member ID card and is answered 24 hours a day

Your home plan is responsible for reimbursing the providers in the out of area Prudential HealthCare HMO plan You should not be asked to make payments except applicable
copays or file a claim form unless you receive authorized treatment from a non Prudential HealthCare provider

Section 5 Mental Conditions Substance Abuse Benefits
You must contact 1 800 647 2220 prior to receiving services A referral from your primary care doctor is not required The vendor will determine and authorize the appropriate number of visits

Mental conditions
What is covered To the extent shown below the Plan provides the following services necessary for the diagnosis and treatment of acute psychiatric conditions including the treatment of mental
illness or disorders Diagnostic evaluation
Psychological testing Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Biologically based Coverage for biologically based mental illness is covered as any other illness Biologically mental illness based mental illness is defined as any mental or nervous condition caused by a biological
disorder of the brain that results in a clinically significant syndrome that substantially limits the person's functioning The diagnoses that are defined as biologically based in adults and
children are schizophrenia schizoaffective disorder bipolar disorder major depressive disorder panic disorder obsessive compulsive disorder attention deficit hyperactivity
disorder autism and drug and alcohol addiction
Outpatient care Up to 40 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year you pay a 10 copay per group or individual session for the first 40 visits all
charges thereafter with the exception of biologically based mental illness which is treated as any other illness

12 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 14
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Prudential HealthCare HMO Richmond 2000
Section 5 Mental Conditions Substance Abuse Benefits continued
Inpatient care Up to 30 days of hospitalization each calendar year you pay nothing for the first 30 days all charges thereafter Mental health inpatient care day limit combines with the substance
abuse inpatient benefit
Intermediate care Intermediate care for mental health accumulates towards the same 30 day inpatient maximum Each two days of intermediate care will count as one inpatient day Intermediate
care consists of continuous treatment in a facility for not less than 3 hours nor more than 12 hours in any 24 hour period It does not include a hospital inpatient stay

What is not covered Care for psychiatric conditions that in the professional judgment of Plan doctors are not subject to significant improvement through relatively short term treatment
Psychiatric evaluation or therapy on court order or as a condition of parole or probation unless determined by a Plan doctor to be necessary and appropriate
Psychological testing when not medically necessary to determine the appropriate treatment of a short term psychiatric condition
Learning disabilities developmental and educational disorders including but not limited to counseling for marital family pastoral and sex therapy

Substance abuse
What is covered This Plan provides medical and hospital services such as acute detoxification services for the medical non psychiatric aspects of substance abuse including alcoholism and the drug
addiction the same as for any other illness or condition and to the extent shown below the services necessary for diagnosis and treatment
Outpatient care All medically necessary visits you pay a 10 copay per visit
Inpatient care Covered under the mental conditions inpatient care benefit described above
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 or package
i e one inhaler one vial ophthalmic medication or insulin You pay a 5 copay per prescription unit or refill for formulary generic drugs or a 15 copay per prescription or
refill for formulary brand name drugs and a 25 copay per prescription or refill for nonformulary drugs per prescription or refill However in no event will the copay exceed the
cost of the prescription
Mail order prescription drug service through Integrated Pharmacy Solutions Inc IPS pharmacies is available to provide up to a three month 90 day supply per refill of
maintenance drugs to treat chronic conditions You pay a 5 copay per prescription unit or refill for formulary generic drugs or a 15 copay per prescription or refill for formulary
brand name drugs and a 25 copay per prescription or refill for non formulary drugs for each three month 90 day supply

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

Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary Non formulary drugs will be covered when prescribed by a Plan doctor Contact
us at 800 856 0764 or visit our website at www aetnaushc com pruhealthcare for information on our formulary or mail order program

Formulary The Prudential Health Care Drug Formulary was developed and is maintained by the development Prudential HealthCare National Pharmacy and Therapeutics committee P T with the
understanding that a well constructed formulary enhances quality of care The P T committee evaluates the clinical use of drugs and develops policies and procedures for
developing new drug therapies and managing the formulary The P T is also responsible for conducting therapeutic class reviews and analyzing new drugs as they enter the market

CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 13 15
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Prudential HealthCare HMO Richmond 2000
Section 5 Prescription Drug Benefits continued
The formulary reflects our medical and pharmaceutical experience in formulary management and rigorous reviews of individual clinical studies

The following are examples of what a copy applies to
Up to a 30 day supply of tablets capsules and liquids to be take orally or as indicated for use the Food and Drug Administration FDA For example Diflucan VC is FDA
indicated as a single dose treatment and a copay will be charged for each tablet The treatment usage for many antibiotics will be for a 10 day supply or less for which one
copay would apply A manufacturer's standard 10 milliliter vial of insulin
Insulin syringes a copay applies to each package of 100 A package of no more than 15 milliliters of any optic or opthalmic product
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 60 milliliters of
topical solutions or lotions 1 manufacturer's smallest standard package containing no more than 60 grams of topical
ointments or creams Up to a 30 day supply of patches a copay applies to each manufacturer's standard package
1 package of oral contraceptives
Covered medications Drugs for which a prescription is required by law and accessories include Oral contraceptive drugs up to a 90 day supply per refill of maintenance and oral

contraceptive drugs may be obtained with a copay applied to each 30 day supply filled at the local participating pharmacy
Diaphragms with a prescription Insulin with a copay charge applied to each vial
Disposable needles and syringes for insulin are covered up to a 30 day supply you pay a separate copay
Fertility drugs
Diabetic supplies except insulin and insulin syringes other disposable needles and syringes contraceptive devices other than diaphragms intravenous fluids and medications

for home use implantable drugs such as Norplant and injectable drugs such as Depo Provera or some fertility drugs are covered under the Medical and Surgical Benefits

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

Section 5 Other Benefits
Dental care The following semi annual dental services are covered when provided by participating Plan dentists you pay a 25 copay per visit

What is covered Cleaning Scaling
Polishing Fluoride
All necessary X rays
Accidental injury Restorative services and supplies necessary to promptly repair or replace sound natural benefit teeth are covered The need for these services must result from an accidental injury You pay

nothing
What is not covered Other dental services not shown as covered

14 CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS 16
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Prudential HealthCare HMO Richmond 2000
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 FFEHB premium any charges for these services do not count toward any FEHB deductibles or put of 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

Vision Program
As a Prudential HealthCare HMO member you can obtain discounts on eyeglasses and frames at designated locations Call 1 800 323 0467 for a list of participating locations

Women's and family health programs
Prudential HealthCare HMO includes a number of programs and features designed specifically for women and families Prudential HealthCare's Starting Right provides valuable information and resources for plan members
who are planning expecting or raising a family

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 And the Prudential HealthCare Bike Helmet Program makes quality bicycle helmets available to people of all ages even non plan members for as little at
10 Call 1 800 MYHEALTH

HealthCare Committed Quitters
A stop smoking plan that combines nicotine replacement therapy NRT and a personalized smoking cessation plan

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

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

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

Section 8 FEHB FACTS
You have a right to information about your HMO
OPM requires that all FEHB plans comply with the Patients Bill of Rights which gives you the right to information about your health plan its networks providers and facilities You can also find out about care management which
includes medical practice guidelines disease management programs and how we determine if procedures are experimental or investigational OPM's website www opm gov lists the specific types of information that we must make
available to you
If you want specific information about us call 1 800 856 0764 or write to Prudential HealthCare 1425 Union Meeting Road P O Box 3013 Blue Bell PA 19422 You may also contact us by fax at 215 775 5870 or visit our website at
www aetnaushc com pruhealthcare
Where do I get Your employing or retirement office can answer your questions and give you a Guide to information about Federal Employees Health Benefits Plans brochures for other plans and other materials you

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

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

We don't determine who is eligible for coverage and in most cases cannot change your enrollment status without information from your employing or retirement office
When are my The benefits in this brochure are effective on January 1 If you are new to this plan your benefits and coverage and premiums begin on the first day of your first pay period that starts on or after
premiums effective January 1 Annuitants premiums begin January 1
What happens When you retire you can usually stay in the FEHB Program Generally you must have been when I retire enrolled in the FEHB Program for the last five years of your Federal service If you do not
meet this requirement you may be eligible for other forms of coverage such as Temporary Continuation of Coverage which is described later in this section

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Prudential HealthCare HMO Richmond 2000
Section 8 FEHB FACTS continued
What types of Self Only coverage is for you alone Self and Family coverage is for you your spouse and coverage are available your unmarried dependent children under age 22 including any foster or step children your

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

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

Are my medical and We will keep your medical and claims information confidential Only the following will claims records have access to it
confidential OPM this Plan and subcontractors when they administer this contract
This plan and appropriate third parties such as other insurance plans and the Office of 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
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 Your enrollment ends unless you cancel your enrollment or

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

What is former If you are divorced from a Federal employee or annuitant you may not continue to get spouse coverage benefits under your former spouse's enrollment But you may be eligible for your own

FEHB coverage under the spouse equity law If you are recently divorced or are anticipating a divorce contact your ex spouse's employing or retirement office to get more information
about your coverage choices
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

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Prudential HealthCare HMO Richmond 2000
Section 8 FEHB FACTS continued
Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal Employees Health Benefits Plans for Temporary Continuation of Coverage and Former Spouse
Enrollees from your employing or retirement office
Key points about TCC
You can pick a new plan If you leave Federal service you can receive TCC for up to 18 months after you
separate If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends If you or your employing office delay processing your request you still have to pay
premiums from the 32nd day after your regular coverage ends even if several months have passed
You pay the total premium and generally a 2 percent administrative charge The government does not share your costs
You receive another 31 day extension of coverage when your TCC enrollment ends unless you cancel your TCC or stop paying the premium
You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll If you leave Federal service your employing office will notify you of your right to enroll in TCC under TCC You must enroll within 60 days of leaving or receiving this notice whichever is

later
Children You must notify your employing or retirement office within 60 days after your child is no longer an eligible family member That office will send you information about
enrolling in TCC You must enroll your child within 60 days after they become eligible for TCC or receive this notice whichever is later

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

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

If you leave Federal service your employing office will notify you if individual coverage is available You must apply in writing to us within 31 days after you receive this notice
However if you are a family member who is losing coverage the employing or retirement office will not notify you You must apply in writing to us within 31 days after you are no
longer eligible for coverage
Your benefits and rates will differ from those under the FEHB Program however you will not have to answer questions about your health and we will not impose a waiting period or
limit your coverage due to pre existing conditions
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 Richmond 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 Richmond 2000
Summary of Benefits for Prudential HealthCare HMO Richmond 2000

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

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

Substance Abuse Covered under mental conditions 13
Outpatient Comprehensive range of services such as diagnosis and treatment of care 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 nothing per house call by a doctor 7
Home health All necessary visits by nurses and health aides You pay nothing 8 care

Mental conditions Up to 40 outpatient visits per year You pay a 10 copay per visit 12
Substance abuse All necessary visits You pay a 10 copay for each covered visit 13

Emergency care Reasonable charges for services and supplies required because of a medical emergency You pay a 50 copay to the hospital for each
emergency room visit or a 10 copay per Urgent Care Center visit and any charges for services that are not covered by this Plan 11

Prescription drugs Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 5 copay per prescription unit or refill for a formulary
generic formulary drug a 15 copay per prescription unit or refill for a formulary brand name drug or a 25 copay per prescription unit
or refill for a non formulary drug Mail order service is available for maintenance drugs and oral contraceptives 13

Dental care Accidental injury benefit you pay nothing Preventive dental care you pay a 25 copayment per semi annual visit 14
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 1,500 per Self Only or
3,000 per Self and Family enrollment per calendar year covered benefits will be provided at 100 This copay maximum does not
include charges for prescription drugs 4
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2000 2000 Rate Rate Information Information for for Prudential HealthCare HMO Richmond Prudential HealthCare HMO Richmond
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 Prudential or contact the agency Health that maintains your Care health benefits Plan enrollment Inc

Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates referred
Non to as Postal Category rates A apply rates to and most Category non Postal B enrollees rates will If you apply are for in a certain special career enrollment employees category If refer you to are the a FEHB career Guide postal for that category
employee or contact but not the a member agency that of maintains a special your postal health employment benefits enrollment class refer to the category definitions in The Guide to

Postal Federal rates Employees apply to most Health career Benefits U S Postal Plans Service for United employees States In Postal 2000 two Service categories Employees of contribution RI 70 rates 2 to referred determine to as which Category rate applies A rates to you and Category B rates will apply for certain career employees If you are a career employee who is 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
Postal States rates do Postal not Service apply to Employees non career RI 70 postal 2 to employees determine which postal rate retirees applies to certain you special postal employment classes or

Postal associate rates members do not apply of to any non postal career employee postal employees organization postal retirees Such persons certain not special subject postal to employment postal rates classes must or refer associate to the members applicable of Guide any postal to employee Federal Employees organization Health Such persons Benefits not Plans 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

Southwest Ohio
Self Only V61 71.74 23.91 155.43 51.81 84.89 10.76 84.89 10.76

Self and Family V62 175.97 82.17 381.27 178.03 207.74 50.40 201.02 57.12

Northern Ohio
Self Only Q91 75.65 25.22 163.91 54.64 89.52 11.35 89.52 11.35

Self and Family Q92 175.97 60.52 381.27 131.13 207.74 28.75 201.02 35.47

RRD 8104408A
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