Enrollment code FX1 Self Only
FX2 Self and Family
Health Alliance HMO East Central Illinois Service Area has commendable accreditation from the NCQA
See the 2000 Guide for more information on NCQA
Service Area Central East Central Southern and Western Illinois Western Indiana and Eastern Iowa
Enrollment code 7X1 Self Only
7X2 Self and Family
Service Area Central Iowa
Visit the OPM website at http www opm gov insure and
this Plan's website at http www healthalliance org
Special Notice Effective January 1 2000 Carroll Lee and Whiteside will no
longer be included in the Plan's service and enrollment area If
you live in one of these counties you have the option of changing
plans during the upcoming Open Season
Authorized for distribution by the
United States
Office of
Personnel Management
Health Alliance HMO 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 7
Section 4 What to do if we deny your claim or request for service 7 9
Section 5 Benefits 9 18
Section 6 General exclusions Things we don't cover 19
Section 7 Limitations Rules that affect your benefits 19 21
Section 8 FEHB facts 21 22
Inspector General Advisory Stop Healthcare Fraud 25
Summary of Benefits Inside back cover
Premiums Back cover
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Health Alliance HMO 2000
Introduction Health Alliance HMO
102 East Main Street
Urbana Illinois 61801
This brochure describes the benefits you can receive from Health Alliance Medical Plans Inc on behalf of itself and
Health Alliance Midwest Inc its wholly owned subsidiary under its contract CS1980 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 Health Alliance 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 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
Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and how they work
How we change for 2000 If you are a current member and want to see how we have changed read this section
How to get benefits Make sure you read this section it tells you how to get services and how we operate
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
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
General exclusions Things we don't cover Look here to see benefits that we will not provide
Limitations Rules that affect your benefits This section describes limits that can affect your benefits
FEHB facts Read this for information about the Federal Employees Health Benefits FEHB Program
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Health Alliance HMO 2000
Section 1 Health Maintenance Organizations
Health maintenance organizations HMOs are health plans that require you to see Plan providers specific physicians
hospitals and other providers that contract with us These providers coordinate your health care services The care you
receive includes preventative care such as routine office visits physical exams well baby care and immunizations as well
as treatment for illness and injury
When you receive services from our providers you will not have to submit claim forms or pay bills However 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 This year you have a right to more information about this Plan care management our changes 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 Plan Your share of the premium will increase as follows if you are enrolled in enrollment code FX the increase is 8.0 for Self Only or 7.5 for Self and Family If you are
enrolled in enrollment code 7X the increase is 10.0 for Self Only and Self and
Family
Under the Prescription Drug Benefit provision the Plan has changed to a three tier
benefit structure Please refer to page 16 for the new prescription drug copayment
amounts
The Plan's service area has expanded to include the following the Central Iowa county
of Carroll and the Southern Illinois counties of Hardin Johnson and Washington
Effective January 1 2000 the Illinois counties of Carroll Lee and Whiteside will no
longer be included in the Plan's service and enrollment area If you live in one of these
counties you have the option of changing plans during the upcoming Open Season
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Health Alliance HMO 2000
Section 3 How to get benefits
What is this Plan's To enroll with us you must live in one of our service areas A service area is a service area
geographic region consisting of one or more counties The county in which you live determines your service area and subsequently your provider network When you
enroll in the Plan you will be required to select a Primary Care Physician in your service area This Physician will coordinate all of your medical care
Should you require specialty or ancillary care your Primary Care Physician will refer you to a provider in your service area If you require care that is not
available within your service area your physician will request an out of network referral from a Plan Medical Director The Plan will notify the referring physician
and you in writing of the decision Please be sure that the out of network service has been approved prior to seeking out of network services in order to assure
coverage The Plan's service areas are listed below
Our Illinois service area is
Decatur Service Area Decatur Memorial Network Macon
Decatur Service Area Decatur St Mary's Network Cass Christian Greene Jersey
Logan Macon Macoupin Mason Menard Montgomery Morgan Sangamon Scott
East Central Illinois Service Area Champaign Clark Coles Cumberland DeWitt
Douglas Edgar Effingham Ford Iroquois Livingston McLean Moultrie Piatt
Shelby Tazewell Vermilion Woodford
Indiana counties included Fountain Vermillion Warren
Macomb Service Area Henderson McDonough Warren
Peoria Service Area Fulton Henry Knox Marshall Peoria Putnam Stark Tazewell
Woodford
Quad Cities Service Area Henry Mercer Rock Island
Iowa county included Scott
Quincy Service Area Adams Brown Hancock Pike Schuyler
Southern Illinois Service Area Franklin Gallatin Hardin Jackson Johnson Perry
Randolph Saline Union Washington Williamson
Springfield Service Area Cass Christian Greene Jersey Logan Macon Macoupin
Mason Menard Montgomery Morgan Sangamon Scott
Our Iowa service area is
Central Iowa Service Area Boone Calhoun Carroll Greene Hamilton Hardin
Marshall Story Tama Webster Wright
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
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Section 3 How to get benefits continued
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 The Plan offers a reciprocity
program for family members living temporarily away from home in an area serviced by
the Plan Under this program family members living away can receive coverage for
many services normally covered only in the home network such as routine care and
diagnostic procedures For additional information on this program or to enroll a family
member call the Plan at 800 851 3379 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 pay for services dollar amount or coinsurance a set percentage of charges Please remember you
must pay this 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 durable medical equipment prosthetic devices
prescription drugs and vision care 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 This Plan has been approved as a mixed model prepayment plan This means care is my health care provided through Plan doctors who practice in medical centers groups or in individual
private offices As discussed below you must choose a primary care doctor You may
select any one of the Plan's primary care doctors whether that doctor practices in a
group or individual setting The Plan also contracts with certain area hospitals
What do I do if my Call us We will help you select a new one 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 need to go into the physician or specialist will make the necessary hospital arrangements and supervise
hospital your care
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Section 3 How to get benefits continued
What do I do if I'm in First call our customer service department at 800 851 3379 If you are new to the the hospital when I FEHB Program we will arrange for you to receive care If you are currently in the
join this Plan FEHB Program and are switching to us your former plan will pay for the hospital stay until
You are discharged not merely moved to an alternative care center or The day your benefits from your former plan run out or
The 92nd day after you became a member of this Plan whichever happens first
These provisions only apply to the person who is hospitalized
How do Except in a medical emergency or when a primary care doctor has designated another I get specialty doctor to see patients when he or she is unavailable you must contact your primary
care care doctor for a referral before seeing any other doctor or obtaining specialty services Referral to a participating specialist is given at the primary care doctor's discretion if
specialists or consultants are required beyond those participating in the Plan the
primary care doctor will make arrangements for appropriate referrals
When you receive a referral from your primary care doctor you must return to the
primary care doctor after the consultation All follow up care must be provided or
authorized by the primary care doctor On referrals the primary care doctor will give
specific instructions to the consultant as to what services are authorized If additional
services or visits are suggested by the consultant you must first check with your
primary care doctor Do not go to the specialist unless your primary care doctor has
arranged for and the Plan has issued an authorization for the referral in advance If you
are receiving services from a doctor who leaves the Plan the Plan will pay for covered
services until the Plan can arrange with you for you to be seen by another participating
doctor
If you need to see a specialist frequently because of a chronic complex or serious
medical condition your primary care physician will develop a treatment plan that
allows you to see your specialist for a certain number of visits without additional
referrals Your primary care physician will use our criteria when creating your
treatment plan
What do I do if I Your primary care physician will decide what treatment you need If they decide to am seeing a
refer you to a specialist ask if you can see your current specialist If your current specialist when I enroll
specialist does not participate with us you must receive treatment from a specialist who
does Generally we will not pay for you to see a specialist who does not participate
with our Plan
What do I do if Call your primary care physician who will arrange for you to see another specialist my specialist You may receive services from your current specialist until we can make arrangements
leaves the for you to see someone else Plan
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Section 3 How to get benefits continued
But what if I Please contact us if you believe your condition is chronic or disabling You may be able have a serious to continue seeing your provider for up to 90 days after we notify you that we are
illness and my terminating our contract with the provider unless the termination is for cause If you provider leaves are in the second or third trimester of pregnancy you may continue to see your
the Plan or this OB GYN until the end of your postpartum care Plan leaves the
Program You may also be able to continue seeing your provider if your plan drops out of the FEHB Program and you enroll in a new FEHB plan Contact the new plan and explain
that you have a serious or chronic condition or are in your second or third trimester
Your new plan will pay for or provide your care for up to 90 days after you receive
notice that your prior plan is leaving the FEHB Program If you are in your second or
third trimester your new plan will pay for the OB GYN care you receive from your
current provider until the end of your postpartum care
How do you Your physician must get our approval before sending you to a hospital referring you to authorize a specialist or recommending follow up care Before giving approval we consider if
medical services the service is medically necessary and if it follows generally accepted medical practice Medical necessity determination of covered health care services under this Plan is
subject to the medical policies presently in effect and adopted or amended by Health
Alliance HMO A copy of the medical policies and procedures relevant to a pending
coverage decision will be made available to members upon written request
How do you decide The Plan considers factors which it determines to be most relevant under the if a service is experimental circumstances such as published reports and articles in the authoritative medical
or investigational scientific and peer review literature or written protocols used by the treating facility or being used by another facility studying substantially the same drug device or medical
treatment This Plan also considers Federal and other government agency approval as
essential to the treatment of an injury or illness by but not limited to the following
American Medical Association U S Surgeon General U S Department of Public
Health the Food and Drug Administration or the National Institutes of Health
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
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Section 4 What to do if we deny your claim or request for service continued
When may I ask You may ask OPM to review the denial after you ask us to reconsider our initial denial OPM to review a or refusal OPM will determine if we correctly applied the terms of our contract when
denial we denied your claim or request for service
What if I have a Call us at 800 851 3379 and we will expedite our review serious or life
threatening condition and you haven't responded
to my request for service
What if you have If we expedite your review due to a serious medical condition and deny your claim we denied my request will inform OPM so that they can give your claim expedited treatment too
for care and my Alternatively you can call OPM's health benefits Contract Division II at 202 606 condition is serious 3818 between 8 a m and 5 p m Serious or life threatening conditions are ones that may
or life threatening cause permanent loss of bodily functions or death if they are not treated as soon as possible
Are there other You must write to OPM and ask them to review our decision within 90 days after we time limits uphold 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
What do I send Your request must be complete or OPM will return it to you You must send the to OPM following 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
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Section 4 What to do if we deny your claim or request for service continued
What if OPM OPM's decision is final There are no other administrative appeals If OPM agrees with upholds the our 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 if I file a lawsuit will 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 BENEFITS
Medical and Surgical Benefits
What is Covered A comprehensive range of preventative 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 judgement of the Plan
doctor such care is necessary and appropriate you pay a 20 copay for a doctor's visit
you pay nothing for home visits by nurses and health aides
The following services are included
Preventative care including well baby care and periodic check ups
Mammograms are covered as follows for women age 35 through age 39 one mammogram during these five years for women age 40 through 49 one
mammogram every one or two years for women age 50 through 64 one
mammogram every year and for women age 65 and above one
mammogram every two years In addition to routine screening
mammograms are covered when prescribed by the doctor as medically
necessary to diagnose or treat your illness
Routine immunizations and boosters
Consultations by specialists
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Medical and Surgical Benefits continued
Diagnostic procedures such as laboratory tests and X rays
Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor The copay is 50 per
pregnancy Referrals to other Plan specialists during the prenatal period are
subject to the 10 office visit copay The mother at her option may remain
in the hospital up to 48 hours after a regular delivery and 96 hours after a
Caesarian delivery Inpatient stays will be extended if medically necessary
If enrollment in the Plan is terminated during pregnancy benefits will not be
provided after coverage under the Plan has ended Ordinary nursery care of
the newborn child during the covered portion of the mother's hospital
confinement for maternity will be covered under either a Self Only or Self
and Family enrollment other care of an infant who requires definitive
treatment will be covered only if the infant is covered under a Self and
Family enrollment
Voluntary sterilization and family planning services
Diagnosis and treatment of diseases of the eye
Allergy testing and treatment including test and treatment materials such as allergy serum
The insertion of internal prosthetic devices such as pacemakers and artificial joints including the cost of the device implantable drugs Dental implants
are not covered
Cornea heart heart lung single double lung kidney liver and pancreas transplants allogeneic donor bone marrow transplants autologous bone
marrow transplants autologous stem cell and peripheral stem cell support
for the following conditions acute lymphocytic or non lymphocytic
leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's
lymphoma advanced neuroblastoma breast cancer excluding Stage IV
multiple myeloma epithelial ovarian cancer and testicular mediastinal
retroperitoneal and ovarian germ cell tumors Medically appropriate
transplants are covered when approved by the Medical Director Related
medical and hospital expenses of the donor are covered
Women who undergo mastectomies may at their option have this procedure performed on an inpatient basis and remain in the hospital up to 48 hours
after the procedure
Dialysis
Chemotherapy radiation therapy and inhalation therapy
Surgical treatment of morbid obesity
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Medical and Surgical Benefits continued
Home health services of nurses and health aides including intravenous fluids and medications when prescribed by your Plan doctor who will periodically
review the program for continuing appropriateness and need All necessary
medical or surgical care in a hospital or extended care facility from Plan
doctors and other Plan providers
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers
Limited Benefits Oral and maxillofacial surgery is provided for nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate and for medical or
surgical procedures occurring within or adjacent to the oral cavity or sinuses including
but not limited to treatment of fractures and excision of tumors and cysts All other
procedures involving the teeth or intra oral areas surrounding the teeth are not covered
including shortening of the mandible or maxillae for cosmetic purposes correction of
malocclusion and any dental care involved in treatment of temporomandibular joint
TMJ pain dysfunction syndrome
Reconstructive surgery will be provided to correct a condition resulting from a 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 Benefits will be provided for breast reconstruction surgery following a
mastectomy including surgery to produce a symmetrical appearance on the other breast
Benefits will be provided for all stages of breast reconstruction following a mastectomy
including treatment of any physical complications including lymphedemas and for
breast prostheses including surgical bras and replacements 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
Diagnosis and treatment of infertility is covered you pay a 10 copay per outpatient
visit Invitro fertilization including embryo transfers and the following types of
artificial insemination are covered intravaginal insemination IVI intracervical
insemination ICI and intrauterine insemination IUI you pay a 10 copay per
outpatient visit or if applicable a 100 copay per inpatient admission cost of donor
sperm donor eggs or cyropreservation is not covered Fertility drugs are covered
Short term rehabilitative therapy physical speech and occupational is provided on an inpatient or outpatient basis for up to two consecutive months per condition if
significant improvement can be expected within two months you pay a 10 copay per
outpatient visit nothing per inpatient visit 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
Spinal manipulations and mobilizations are covered for up to 60 treatments on an inpatient or outpatient basis per condition for short term acute care of musculoskeletal
spinal disorders where significant improvement can be expected within 60 treatments
you pay a 10 copay per outpatient visit nothing per inpatient visit Hot cold pack
therapy used in conjunction with approved manipulations and mobilizations is covered
Maintenance services will not be covered Diagnostic tests X rays and physical therapy
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Medical and Surgical Benefits continued
must be ordered by your primary care physician and performed at a Plan facility All
visits must be referred by your primary care physician and authorized in advance by a
Plan Medical Director
Cardiac rehabilitation following a heart transplant bypass surgery or a myocardial infarction is provided at a Plan facility for up to 8 consecutive weeks you pay nothing
Orthopedic devices such as braces foot orthotics You pay 20 of charges
Prosthetic devices such as artificial limbs and the first pair of lenses following cataract removal is covered You pay 20 of charges
Durable medical equipment such as wheelchairs and hospital beds Rental items are covered up to purchase price You pay 20 of charges
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
Infertility treatment if voluntarily surgically sterilized
Hearing aids
Long term rehabilitative therapy
Homemaker services
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 a 100 copay per
inpatient admission 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 up to 120 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 All necessary services are covered including
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Hospital Extended Care Benefits continued
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
Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
Limited benefits
Inpatient dental Hospitalization for certain dental procedures is covered when a Plan doctor determines procedures there is a need for hospitalization for reasons totally unrelated to the dental procedure
the Plan will cover the hospitalization but not the cost of the professional dental
services Conditions for which hospitalization would be covered include hemophilia and
heart disease the need for anesthesia by itself is not such a condition
Acute inpatient Hospitalization for medical treatment of substance abuse is limited to emergency care detoxification diagnosis treatment of medical conditions and medical management of withdrawal
symptoms acute detoxification if the Plan doctor determines that outpatient
management is not medically appropriate See page 16 for nonmedical substance abuse
benefits
What is not covered Personal comfort items such as telephone and television
Cost related to the storage of blood of directed designated donors
Custodial care rest cures domiciliary or convalescent care
Emergency Benefits
What is a medical emergency A medical emergency is the sudden and unexpected onset of a condition or an injury that 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 should notify the Plan within 48 hours It is
your responsibility to ensure that the Plan has been timely notified
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Emergency Benefits continued
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 or 10 per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a
hospital inpatient services are subject to the hospital admission copay and the
emergency care 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 follow up care recommended by non Plan providers must be
approved by the Plan or provided by Plan providers
Plan pays Reasonable charges for emergency care services to the extent the services would have
been covered if received from Plan providers
You pay 50 per hospital emergency room visit or 10 per urgent care center visit for emergency services that are covered benefits of this Plan If the emergency results in admission to a
hospital inpatient services are subject to the hospital admission copay and the
emergency care copay is waived
What is covered Emergency care at a doctor's office or an urgent care center
Emergency care as an outpatient or inpatient at a hospital including doctors services
Ambulance service approved by the Plan
What is not covered Elective care or nonemergency care
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Health Alliance HMO 2000
Emergency Benefits continued
Emergency care provided outside the service area if the need for care could have been foreseen before leaving the service area
Medical and hospital costs resulting from a normal full term delivery of a baby outside the service area Normal full term shall be defined as equal to or greater
than 36 weeks
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 7
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 the treatment of
mental illness or disorders
Diagnostic evaluation
Psychological testing
Psychiatric treatment including individual and group therapy
Hospitalization including inpatient professional services
Outpatient care Up to 30 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year you pay a 15 copay per visit for each covered visit all charges
thereafter Group outpatient mental health visits may be substituted on a two to one
basis for individual mental health care visits
Inpatient care Up to 30 days of hospitalization each calendar year you pay a 100 copay per hospital admission all charges after the first 30 days Inpatient days may be exchanged for
outpatient days at the rate of one inpatient day for two outpatient day treatments
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
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Health Alliance HMO 2000
Mental Conditions Substance Abuse Benefits continued
Psychological testing when not medically necessary to determine the appropriate treatment of a short term psychiatric condition
Substance Abuse
What is covered This Plan provides medical and hospital services such as acute detoxification services for the medical non psychiatric aspects of substance abuse including alcoholism and
drug addiction the same as for any other illness or condition and all services necessary
for diagnosis and treatment
Outpatient care Up to the approved number of outpatient visits to Plan providers for treatment each calendar year you pay nothing
Inpatient care Up to the approved number of days per calendar year for hospitalization you pay a 100 copay per admission Inpatient days may be exchanged for outpatient days at the
rate of one inpatient day for two outpatient day treatments
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 at a Plan pharmacy will be dispensed for up to a 34 day supply or manufacturer's standard
package You pay a 7 copay per prescription unit or refill for generic a 14 copay for
brand name drugs on the Plan's formulary and a 25 copay for brand name drugs that
are not on the Plan's formulary If the physician allows substitution and the member
prefers a brand name drug on the formulary instead of the generic if available the
member pays 14 plus the difference in cost between the generic and the brand name
drug If the physician prescribes a brand name drug on the formulary and does not
allow substitution the member will pay only the 14 copay
Drugs are prescribed by Plan physicians and dispensed in accordance with the Plan's
drug formulary The Plan's formulary offers a variety of drug choices in each
therapeutic category The Pharmacy and Therapeutic Committee at the Plan evaluates
individual drugs and therapeutic class of drugs on a regular basis The addition deletion
of drugs to the formulary is determined by this committee
Manufacturer's standard package includes but is not limited to
Topical cream solution gel or ointment Otic ophthalmic or nasal preparation nasal or oral inhaler
One 10 ml vial of insulin or 5 x 1.5 ml Novolin Penfill etc Antibiotic suspensions
In addition the Plan offers a Mail Order Prescription Drug Program Members will be
limited to a 90 day supply per prescription and will be assessed a 14 generic copay a
28 brand name copay for drugs on the Plan's formulary and a 50 copay for brand
name drugs that are not on the Plan's formulary If you are currently taking prescription
medications on a regular basis the Mail Order Drug Program may help you save money
on the cost of your medication The benefit may not apply to certain medications and
there may be some exceptions due to the manufacturer's standard packaging For further
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Health Alliance HMO 2000
Prescription Drug Benefits continued
information please contact the Health Alliance Customer Service Department at
800 851 3379
Covered medications and accessories include
Drugs for which a prescription is required by law Insulin insulin syringes and needles
Disposable needles and syringes needed to inject covered prescribed medication Intravenous fluids and medication for home use implantable drugs and some
injectable drugs are covered under Medical and Surgical Benefits Covered under
Home health services on page 11
Drugs for treatment of infertility Requires prior authorization by the Plan FDA approved prescription drugs and devices for birth control
Drugs for treatment of impotence When the following conditions are met Must be medically necessary
Member must be 18 years or older
Covered quantity limited to four tablets per 34 day period
Retail pharmacy access only no mail order
Member cannot be on Nitrates
No coverage for women
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 Smoking cessation drugs and medication including nicotine patches
Other Benefits
Dental care Accidental injury benefit Restorative services and supplies necessary to promptly repair but not replace sound
natural teeth are covered when the need for these services result from an accidental
injury you pay nothing
What is not covered Other dental services not shown as covered
Vision care
What is covered In addition to the medical and surgical benefits provided for diagnosis and treatment of diseases of the eye annual eye refractions to provide a written lens prescription for
eyeglasses may be obtained from Plan optometrists
Eye refractions including lens prescriptions You pay a 10 copay per visit if you are
age 17 and under a 20 copay per visit if you are age 18 and over
What is not covered Eye exercises
Eyeglasses frames contact lenses or the fitting of contact lenses
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Health Alliance HMO 2000
Non FEHB Benefits Available to Plan Members
Medicare prepaid This Plan offers Medicare recipients the opportunity to enroll in the Plan through plan enrollment Medicare As indicated on page 19 annuitants and former spouses with FEHB coverage
and Medicare Part B may elect to drop their FEHB coverage and enroll in a Medicare
prepaid plan when one is available in their area They may then later reenroll in the
FEHB Program Most Federal annuitants have Medicare Part A Those without
Medicare Part A may join this Medicare prepaid plan but will probably have to pay for
hospital coverage in addition to the Part B premium Before you join the plan ask
whether the plan covers hospital benefits and if so what you will have to pay Contact
your retirement system for information on dropping your FEHB enrollment and
changing to a Medicare prepaid plan Contact the Plan at 800 965 4022 for information
on the Medicare prepaid plan and the cost of that enrollment
Benefits on this page are not part of the FEHB contract
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Health Alliance HMO 2000
Section 6 General exclusions Things we don't cover
The exclusions in this section apply to all benefits Although we may list a specific service as a benefit we will not
cover it unless your Plan doctor determines it is medically necessary to prevent diagnose or treat your illness or condition
We do not cover 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 or eligible selfreferred services
Experimental or investigational procedures treatments drugs or devices Procedures services drugs and supplies related to abortions except when the life of the mother would be endangered
if the fetus were carried to term
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 son 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 800 638 6833 For information
on the Medicare Choice plan offered by this Plan see page 18
Other group When anyone has coverage with us and with another group health plan it is called insurance double coverage You must tell us if you or a family member has double coverage
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
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Health Alliance HMO 2000
Section 7 Limitations Rules that affect your benefits continued
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 beyond our control unable to provide them In that case we will make all reasonable efforts to provide you
with necessary care
When others are When you receive money to compensate you for medical or hospital care for injuries or responsible for injuries illness that another person caused you must reimburse us for whatever services we paid
for We will cover the cost of treatment that exceeds the amount you received in the
settlement If you do not seek damages you must agree to let us try This is called
subrogation If you need more information contact us for our subrogation procedures
TRICARE TRICARE is the health care program for members eligible dependents and retirees of the military TRICARE includes the CHAMPUS program If both TRICARE and this
Plan cover you we are the primary payer See your TRICARE Health Benefits Advisor
if you have questions about TRICARE coverage
Workers compensation We do not cover services that
You need because of a workplace related disease or injury that the Office of Workers Compensation Programs OWCP or a similar Federal or State agency
determine they must provide
OWCP or a similar agency pays for through a third party injury settlement or other similar proceeding that is based on a claim you filed under OWCP or similar laws
Once the OWCP or similar agency has paid its maximum benefits for your treatment
we will provide your benefits
Medicaid We pay first if both Medicaid and this Plan cover you
Other Government We do not cover services and supplies that a local State or Federal Government Agencies agency directly or indirectly pays for
If you have a malpractice If you have a malpractice claim because of services you did or did not receive from a claim plan provider it must go to binding arbitration Contact us about how to begin our
binding arbitration process
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Health Alliance HMO 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 information about you the right to information about your health plan its networks providers and
your HMO facilities You can also find out about care management which includes medical practice guidelines disease management programs and how we determine if procedures
are experimental or investigational OPM's website www opm gov lists the specific
types of information that we must make available to you
If you want specific information about us call 800 851 3379 or write to 102 East Main
St Urbana IL 61801 You may also contact us by fax at 217 337 3438 or visit our
website at www healthalliance org
Where do I get information Your employing or retirement office can answer your questions and give you a Guide about enrolling in the to Federal Employees Health Benefits Plans brochures for other plans and other
FEHB Program materials you need to make an informed decision about
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 benefits and your coverage and premiums begin on the first day of your first pay period that starts on
premiums effective or after January 1 Annuitants premiums begin January 1
What happens When you retire you can usually stay in the FEHB Program Generally you must have when I retire been 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 coverage are Self Only coverage is for you alone Self and Family coverage is for you your spouse available for me and your unmarried dependent children under age 22 including any foster or step
and my family children your 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 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
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Health Alliance HMO 2000
Section 8 FEHB FACTS continued
If you or one of your family members is enrolled in one FEHB plan that person may not
be enrolled in another FEHB plan
Are my medical We will keep your medical and claims information confidential Only the following
and claims records will have access to it confidential
OPM this Plan and subcontractors when they administer this contract 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 cards We will send you an Identification ID card Use your copy of the Health Benefits Election 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 deductible Your old plan's deductible continues until our coverage begins under my old plan
Pre existing We will not refuse to cover the treatment of a condition that you or a family member Conditions had before you enrolled in this Plan solely because you had the condition before you
enrolled
When you lose benefits
What happens if You will receive an additional 31 days of coverage for no additional premium when my enrollment in
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 spouse coverage benefits under your former spouse's enrollment But you may be eligible for your
own FEHB coverage under the spouse equity law If you are recently divorced or are
anticipating a divorce contact your ex spouse's employing or retirement office to get
more information about your coverage choices
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Health Alliance HMO 2000
When you lose benefits continued
What is TCC Temporary Continuation of Coverage TCC If you leave Federal service or if you lose coverage because you no longer qualify as a family member you may be eligible
for TCC For example you can receive TCC if you are not able to continue your
FEHB enrollment after you retire You may not elect TCC if you are fired from your
Federal job due to gross misconduct
Get the RI 79 27 which describes TCC and the RI 70 5 the Guide to Federal
Employees Health Benefits Plans for Temporary Continuation of Coverage and
Former Spouse Enrollees from your employing or retirement office
Key points about TCC
You can pick a new plan If you leave Federal service you can receive TCC for up to 18 months after you
separate
If you no longer qualify as a family member you can receive TCC for up to 36 months
Your TCC enrollment starts after regular coverage ends If you or your employing office delay processing your request you still have to
pay premiums from the 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 cost
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 in TCC enroll 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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Health Alliance HMO 2000
When you lose benefits continued
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 Certificate of Coverage that indicates how long you have been enrolled with us You can use this
Group Health certificate when getting health insurance or other health care coverage You must Plan Coverage 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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Health Inspector Alliance HMO General 2000 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 800 851 3379 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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Health Alliance HMO 2000
Summary of Benefits for Health Alliance HMO 2000
Do not rely on this chart alone All benefits are provided in full unless otherwise indicated subject to the limitations and exclusions set
forth in the brochure This chart merely summarizes certain important expenses covered by this 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 Hospital Comprehensive range of medical and surgical services without dollar or day 12 Care 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 a 100 copay per admission
Extended All necessary services up to 120 days You pay nothing 12 Care
Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days of 15
Conditions inpatient care per year You pay 100 copay per hospital admission
Substance All necessary treatment You pay a 100 copay per admission 16 Abuse
Outpatient Comprehensive range of services such as diagnosis and treatment of illness or 9 care injury including specialist's care preventive care including well baby care
periodic check ups and routine immunizations laboratory tests and X Rays
You pay a 10 copay per office visit 20 per house call by a doctor
Home
Health Care All necessary visit by nurses and health aides You pay nothing 11
Maternity Prenatal
All outpatient routine prenatal and postnatal care You pay 50 copay per 10 Postnatal
pregnancy Care provided by specialists during the prenatal period is subject to Care
the 10 office visit copay
Mental
Conditions Up to 30 outpatient visits per year You pay a 15 copay per visit 15
Substance
Abuse All necessary treatment You pay nothing 16
Emergency Reasonable charges for services and supplies required because of a medical 13 Care emergency You pay a 50 copay to the hospital for each emergency room visit
and any charges for services that are not covered by this Plan
Prescription Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay a 16 drugs 7 copay per prescription unit or refill for generic drugs a 14 for brand name
drugs on the Plan's formulary and 25 for brand name drugs that are not on the
Plan's formulary Under the Mail Order Prescription Drug Program you pay
14 for generic drugs 28 for brand name drugs on the Plan's formulary and
50 for brand name drugs that are not on the Plan's formulary for up to a 90day
supply prescription unit or refill
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Health Alliance HMO 2000
Benefits Plan Pays provides Page
Dental care Accidental injury benefit You pay nothing 17
Vision care One refraction annually You pay a 10 copay per visit if you are age 17 and 17 under a 20 copay per visit if you are age 18 and over
Out of pocket Copay are required for a few benefits however after your out of pocket 5 limit 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 your copay on durable medical
equipment prosthetic devices prescription drugs and vision care
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Health Alliance HMO 2000
Authorized for Distribution by the
United States Office of Personnel Management
2000 Rate Information for
Health Alliance HMO
Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the FEHB Guide for that category or contact the agency that maintains your health benefits enrollment
Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates referred to as Category A rates and Category B rates will apply for certain career employees If you are a career postal employee
but not a member of a special postal employment class refer to the category definitions in The Guide to Federal
Employees Health Benefits Plans for United States Postal Service Employees RI 70 2 to determine which rate applies
to you
Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes or
associate members of any postal employee organization Such persons not subject to postal rates must refer to the
applicable Guide to Federal Employees Health Benefits Plans
Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Code Gov't Your Gov't Your USPS Your USPS Your
Enrollment Share Share Share Share Share Share Share Share
Fountain Vermillion Warren Counties IN
Self Only FX1 78.83 31.90 170.80 69.12 93.06 17.67 93.26 17.47
Self and Family FX2 175.97 82.49 381.27 178.73 207.74 50.72 201.02 57.44
Central E Central South West IL
Self Only FX1 78.83 31.90 170.80 69.12 93.06 17.67 93.26 17.47
Self and Family FX2 175.97 82.49 381.27 178.73 207.74 50.72 201.02 57.44
Central Iowa
Self Only 7X1 67.97 22.65 147.26 49.08 80.43 10.19 80.43 10.19
Self and Family 7X2 164.84 54.94 357.14 119.05 195.05 24.73 195.05 24.73
28 29