Serving The Peninsula Southside Hampton Roads Richmond Fredericksburg Charlottesville Roanoke and the New River Valley areas Virginia
Enrollment in this Plan is limited see page 6 for enrollment requirements
Enrollment code X81 Self Only
X82 Self and Family
This Plan has a commendable status 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 trigon com
Authorized for distribution by the
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Table of Contents Page
Introduction 3
Plain language 3
How to use this brochure 3
Section 1 Health Maintenance Organizations 4
Section 2 How we change for 2000 4
Section 3 How to get benefits 5
Section 4 What to do if we deny your claim or request for service 8
Section 5 Benefits 10
Section 6 General exclusions Things we don't cover 21
Section 7 Limitations Rules that affect your benefits 21
Section 8 FEHB FACTS 22
Inspector General Advisory Stop Healthcare Fraud 26
Summary of benefits Inside back cover
Premiums Back cover
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Introduction
Trigon HealthKeepers offered by HealthKeepers Inc P O Box 26623
Richmond VA 23285 0031
This brochure describes the benefits you can receive from HealthKeepers Inc under its contract CS 2091 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 4 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 under standable 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 HealthKeepers Inc as this Plan throughout this brochure even though in other legal documents you will see a plan referred to as a carrier
These changes do not affect the benefits or services we provide We have rewritten this brochure only to make it more understandable
We have not re written the Benefits section of this brochure You will find new benefits language next year
How to Use This Brochure
This brochure has eight sections Each section has important information you should read If you want to compare this Plan's benefits with benefits from other FEHB plans you will find that the brochures have the same format and similar information to
make comparisons easier
1 Health Maintenance Organizations HMO This Plan is an HMO Turn to this section for a brief description of HMOs and how they work
2 How we change for 2000 If you are a current member and want to see how we have changed read this section
3 How to get benefits Make sure you read this section it tells you how to get services and how we operate
4 What to do if we deny your claim or request for service This section tells you what to do if you disagree with our decision not to pay for your claim or to deny your request for a service
5 Benefits Look here to see the benefits we will provide as well as specific exclusions and limitations You will also find information about non FEHB benefits
6 General exclusions Things we don't cover Look here to see benefits that we will not provide
7 Limitations Rules that affect your benefits This section describes limits that can affect your benefits
8 FEHB FACTS Read this for information about the Federal Employees Health Benefits FEHB Program
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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 or group of physicians 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 changes To keep your premium as low as possible OPM has set a minimum copay of 10 for all 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 Trigon HealthKeepers non postal premium will decrease by Plan 31.8 for Self Only or 46.6 for Self and Family
Clinical trials for cancer including ovarian cancer trials are covered when certain requirements are met
Coverage is added for diabetic lancets under the prescription drug benefit Previously coverage was excluded
Chiropractic services will be covered when authorized and provided by the Plan's designated provider for this service listed in the Directory of Providers You pay a
10 copayment per visit and you are limited to 20 visits per member per calendar year Previously coverage was excluded
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Hospice care benefits have been added Previously there was no specific benefit
The prescription drug benefit is changed to a three tier benefit You pay a 5 copay first tier a 10 copay second tier or a 25 copay third tier per
prescription unit or refill Previously the prescription drug benefit copay was 5 generic or 10 brand name
Vision care benefits are expanded to cover one eye refraction every year regardless of age when received from the Plan's vision care vendor You pay a
10 copay per visit Previously eye refractions were limited to one per year for members under age 19 and one every two years for members over age 19
Previously members over age 19 were covered only for one refraction every two years and the copay for all refractions was 5 per visit
Section 3 How to Get Benefits
What is this To enroll with us you must live or work in our service area This is where our Plan's service providers practice Our service area is the entire Hampton Roads area both the
area Peninsula and Southside Tidewater the Richmond area the Fredericksburg area the Charlottesville area the Roanoke area and the New River Valley area
of Virginia Our service area is
The Virginia Cities of Charlottesville Norfolk Salem
Chesapeake Petersburg Suffolk Colonial Heights Poquoson Virginia Beach
Fredericksburg Portsmouth Williamsburg Hampton Radford
Hopewell Richmond Newport News Roanoke
The Virginia Counties of Albemarle Greene New Kent
Amelia Hanover Nottoway Botetourt Henrico Orange
Caroline Isle of Wright Powhatan Charles City James City Prince Edward
Chesterfield King and Queen Prince George Craig King George Pulaski
Cumberland King William Richmond Windiddie Louisa Roanoke
Essex Lunenburg Spotsylvania Fluvanna Madison Stafford
Franklin Mathews Surry Giles Middlesex Sussex
Gloucester Montgomery Westmoreland Goochland Nelson York
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
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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 forservice
plan or an HMO that has agreements with affiliates in other areas
The Trigon HealthKeepers service area is the area in which HealthKeepers Inc is licensed to sell Trigon HealthKeepers coverage If you are traveling outside of
the service area and have an unexpected illness or injury requiring immediate attention you can access your benefits by calling HMO Blue USA at the number
on your ID card The coordinator will put you in touch with an affiliated Blue Cross and Blue Shield HMO near your location and they will help you find a
participating physician You will not be required to pay the provider when he or she renders the service however you will be responsible for your urgent care
copayment when you return home Certain types of elective care such as routine allergy shots or having a full term baby are not covered when they can be
reasonably foreseen before traveling outside the service area
Trigon HealthKeepers gives you and your covered dependents the flexibility to become Guest Members of an affiliated Blue Cross Blue Shield HMO when
staying outside the Trigon HealthKeepers service area for at least 90 days To join contact our Member Services Department for a Guest Membership
application An Away From Home coordinator will make all the necessary arrangements for you or your dependents to access your Trigon HealthKeepers
benefits while away from home A special Guest Membership ID card will besent to you for your dependents to use when medical care is needed
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 I pay for services dollar amount or coinsurance a set percentage of charges Please remember you must pay
this amount when you receive services except for routine prenatal and postnatal office visits for maternity care
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 calendar year This is called a catastrophic limit However copayments or
coinsurance for your prescription drugs dental services vision care chiropractic services or outpatient mental health and substance abuse services 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 submit claims services 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 HealthKeepers Inc is a mixed model HMO offering both the individual practice my health care and the group practice modes of delivery Members have access to all Plan specialists when
authorized by their primary care doctor
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What do I do if my primary Call us We will help you select a new one care physician leaves the
Plan
What do I do if I need to go Talk to your Plan physician If you need to be hospitalized your primary care physician into the hospital or specialist will make the necessary hospital arrangements and supervise your care
What do I do if I'm in the First call our customer service department at 1 800 421 1880 or in the Richmond area at hospital when I join this 358 7390 If you are new to the FEHB Program we will arrange for you to receive care If
Plan you are currently in the 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 I get specialty care Your primary care physician will arrange your referral to a specialist Services of other providers are covered only when there has been a referral authorized by the
member's primary care doctor with the exception of all services except inpatient hospital services and outpatient surgery received from a Plan participating obstetriciangynecologist
in the care of or related to the female reproductive system and breasts
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 Your primary care
physician will get authorization or approval beforehand
What do I do if I am seeing Your primary care physician will decide what treatment you need If they decide a specialist when I enroll To refer you to a specialist ask if you can see your current specialist If your current
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 my specialist Call your primary care physician who will arrange for you to see another specialist You leaves the Plan may receive services from your current specialist until we can make arrangements for you
to see someone else
But what if I have a serious Please contact us if you believe your condition is chronic or disabling You may be able to illness and my provider continue seeing your provider for up to 90 days after we notify you that we are terminating
leaves the Plan or this Plan our contract with the provider unless the termination is for cause If you are in the second leaves the Program or third trimester of pregnancy you may continue to see your OB GYN until the end of
your postpartum care
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
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How do you authorize Your 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 if a Any service or supply may be determined to be experimental or investigational in the Plan's service is experimental or sole discretion based on the following four criteria
investigational
1 Any supply or drug must have received final approval to market by the United States Food and Drug Administration
2 There must be sufficient information in the peer reviewed medical and scientific literature to enable the Plan to make conclusions about safety and efficacy
3 The available scientific evidence must demonstrate a beneficial effect on health outcomes outside a research setting and
4 The service or supply must be as safe and effective outside a research setting as existing diagnostic or therapeutic alternatives
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 OPM to You may ask OPM to review the denial after you ask us to reconsider our initial denial or review a denial refusal OPM will determine if we correctly applied the terms of our contract when we
denied your claim or request for service
What if I have a serious or Call us at 800 421 1880 and we will expedite our review life threatening condition
and you haven't responded to my request for service
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What if you have denied my If we expedite your review due to a serious medical condition and deny your claim we will request for care and my inform OPM so that they can give your claim expedited treatment too Alternatively you can
condition is serious or life call OPM's health benefits Contracts Division 3 at 202 606 0755 between 8 a m and 5 threatening p m Eastern Time 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
Are there other time You must write to OPM and ask them to review our decision within 90 days after we limits Uphold our initial denial or refusal of service You may also ask OPM to review your 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 to OPM Your request must be complete or OPM will return it to you You must send the 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 the request Those who have a legal right to file a disputed claim with OPM are 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 my Send your request for review to Office of Personnel Management Office of Insurance disputed claim to OPM Programs Contract Division III P O Box 436 Washington D C 20044
What if OPM upholds the OPM's decision is final There are no other administrative appeals If OPM agrees with Plan's denial our decision your only recourse is to sue
If you decide to sue you must file the suit against OPM in Federal court by December 31 of the third year after the year in which you received the disputed services or supplies
What laws apply if I file a Federal law governs your lawsuit benefits and payment of benefits The Federal court will 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
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Your records and the Chapter 89 of title 5 United States Code allows OPM to use the information it collects 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 Plan doctors and other Plan providers provide a comprehensive range of preventive diagnostic and treatment services This includes all necessary office visits you pay a 10
primary care doctor office visit copay and a 20 copay for authorized specialty care doctor office visits but no additional copay for laboratory tests and x rays when provided
at this visit Within the service area house calls will be provided if in the judgment of the Plan doctor such care is necessary and appropriate you pay a 20 copay for a doctor's
house call and nothing for home visits by nurses and health aides You pay a 20 copay for outpatient surgery received in a doctor's office other than that of the primary care
doctor and a 50 copay for outpatient surgery received in a freestanding or hospital based center
The following services are included and subject to the office visit copay unless stated otherwise
Preventive services The following preventive health services are covered Except as noted your primary care doctor must perform all preventive services
1 Well Child care from birth 2 Periodic health assessments for adults and children including screening x rays
laboratory services digital rectal examinations flexible sigmoidoscopies Prostate Specific Antigen PSA tests and immunizations in accordance with
recommendations of the American College of Physicians and the American Academy of Pediatrics so long as they are consistent with accepted medical
practices as determined by the HMO 3 Mammograms as ordered by an HMO physician and no less frequently than the
following One screening mammogram for a member age 35 through 39
Once screening mammogram every other year for a member age 40 through 49 and
One screening mammogram annually for a member age 50 and over No primary care doctor referral is necessary for a member to obtain a
mammogram 4 Vision and hearing screening when performed by your primary care doctor for
members up to age 18 5 An annual gynecological examination which consists of a breast exam pelvic
exam and annual testing performed by any FDA approved gynecologic cytology screening technologies including Pap smears is covered for female Members
when performed by Your Primary Care Physician or an obstetrician gynecologist who is an HMO Physician No Primary Care Physician referral is necessary
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Health Education health education services are covered when authorized or furnished by the Plan This includes outpatient self management training and
education therapy including medical nutrition therapy furnished to Members with diabetes
Consultations by specialists when authorized by your primary care doctor
X ray and Laboratory All x ray and laboratory tests services and materials including diagnostic x rays x ray therapy mammography chemotherapy
fluoroscopy electrocardiograms laboratory tests and therapeutic radiology services are provided when authorized in advance by your primary care doctor and performed
by the designated HMO providers for these covered services
Maternity Care Complete obstetrical maternity care for all covered females including prenatal delivery and postnatal care by a Plan doctor Copays apply only to
any diagnostic testing such as ultrasounds stress tests and amniocentesis Copays are waived for routine prenatal and postnatal office visits The mother at her option
may remain in the hospital up to 48 hours after a regular delivery and 96 hours after a caesarean 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
Family Planning Voluntary family planning services authorized by your primary care doctor are provided Covered services include tubal ligations and vasectomies
prescription contraceptive devices and birth control pills as covered by your prescription drug benefit
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
Organ and Tissue Transplants Cornea heart heart lung kidney liver lung single or double pancreas pancreas kidney small bowel and small bowel liver
transplants allogeneic donor bone marrow transplants autologous bone marrow transplants autologous stem cell and peripheral stem cell support for homozygous
sickle cell anemia acute lymphocytic or non lymphocytic leukemia advanced Hodgkin's lymphoma advanced non Hodgkin's lymphoma advanced
neuroblastoma testicular mediastinal retroperitoneal and ovarian germ cell tumors breast cancer multiple myeloma and epithelial ovarian cancer Related medical and
hospital expenses of the donor are covered when the recipient is covered by this Plan
Mastectomies 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
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Chemotherapy radiation therapy and inhalation therapy
Cardiac rehabilitation therapy as medically necessary when performed by a Plan provider and authorized by the Plan
Surgical treatment of morbid obesity
Treatment for sleep disorders
Home health services of a licensed health care profession on a part time or intermittent basis including intravenous fluids and medications when authorized by
your Plan doctor who will periodically review the program for continuing appropriateness and need
All necessary medical or surgical care in a hospital or extended care facility from Plan doctors and other Plan providers at no additional cost to you
Clinical trials for cancer The following definitions apply Cooperative group means a formal network of facilities that collaborate on research
projects and have an established NIH National Institutes of Health approved peer review program operating within the group Cooperative group includes i the
National Cancer Institute Clinical Cooperative Group and ii the National Cancer Institute Community Clinical Oncology Program Multiple project assurance contract
means a contract between an institution and the Federal Department of Health and Human Services that defines the relationship of the institution to the Federal
Department of Health and Human Services and sets out the responsibilities of the institution and the procedures that will be used by the institution to protect human
subjects
The Plan will cover clinical trials for cancer including ovarian cancer trials when the following requirements are met
Coverage will be provided if the treatment is being conducted in a Phase II Phase III or Phase IV clinical trial Coverage may be provided on a case by case basis if
the treatment is being provided in a Phase I clinical trial Clinical trials must be approved by one of the following
NCI National Cancer Institute An NCI cooperative group or NCI center
The FDA Federal Food and Drug Administration in the form of an investigational new drug application The Federal Department of Veterans Affairs
or An institutional review board of an institution in the Commonwealth of Virginia
that has a multiple project assurance contract approved by the Office of Protection from Research Risks of the NCI
The facility and personnel providing the treatment shall be capable of doing so by virtue of their experience training and expertise
Coverage shall be provided only if There is no clearly superior non investigational treatment alternative
The available clinical or preclinical data provide a reasonable expectation that the treatment will be at least as effective as the non investigational alternative
and The member and the physician or health care provider who provides services
to the member under this paragraph conclude that the member's participation in the clinical trial would be appropriate
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Coverage does not include the cost of non health care services such as travel or lodging costs associated with managing the research associated with the clinical trial
or the cost of the investigational drug or device
Limited Benefits Chiropractic services when authorized and provided by the Plan's designated provider for this service listed in the directory of Providers You pay a 10
copayment per visit and you are limited to 20 visits per member per calendar year
Oral and maxillofacial surgery Benefits for the following functional repairs are provided when arranged by your primary care doctor and authorized by the plan
nondental surgical and hospitalization procedures for congenital defects such as cleft lip and cleft palate
medically necessary medical or surgical procedures occurring within or adjacent to the oral cavity or sinuses or related to temporomandibular joint TMJ pain
dysfunction syndrome All other procedures involving the teeth or intra oral areas surrounding the teeth
are not covered
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 A patient and her attending physician may decide whether
to have breast reconstruction following a mastectomy and whether surgery on the other breast is needed to produce a symmetrical appearance
Rehabilitative Services When performed by a Plan provider and authorized by the Plan short term rehabilitative therapy physical speech and occupational is
provided on an inpatient or outpatient basis for up to 90 days per condition if significant improvement can be expected within 90 days you pay a 20 copay per
outpatient session Speech therapy is limited to treatment of certain speech impairments of organic origin Occupational therapy is limited to services that assist
the member to achieve and maintain self care and improved functioning in other activities of daily living
Diagnosis and treatment of infertility is covered you pay 20 per outpatient visit The following types of artificial insemination are covered according to accepted
standards of medical practice and when authorized in advance by the Plan intravaginal insemination IVI intracervical insemination ICI and intrauterine
insemination IUI you pay a 20 copay per outpatient visit the cost of donor sperm is not covered Fertility drugs are not covered Other assisted reproductive
technology ART procedures such as in vitro fertilization and embryo transfer are not covered
Standard Durable Medical Equipment Rental or purchase as determined by the Plan of standard durable medical equipment including prosthetics breast
prostheses surgical bras and orthotics is covered if authorized as medically necessary by the Plan Durable medical equipment must be obtained from the
designated Plan provider for this service Durable medical equipment is limited to 1,000 per member per calendar year for any combination of items you pay all
charges thereafter
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Early intervention services are covered up to 5,000 per member per calendar year for any combination of services Early intervention services are the medically
necessary speech and language therapy occupational therapy physical therapy and assistive technology services and devices for covered dependents from birth to age
three The dependent must be certified by the Department of Mental Health Mental Retardation and Substance Abuse Services as eligible for services under Part H of
the Individuals with Disabilities Education Act Medically necessary early intervention services include those designed to help an individual attain or retain the
capability to function age appropriately within his or her environment It also includes services that enhance functional ability without effecting a cure
Podiatric services limited to services for diabetic foot debridement
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
Services for or related to reversal of voluntary surgically induced sterility
Services for or related to surgery primarily for cosmetic purposes
Transplants not listed as covered
Services for or related to routine vision and hearing care except as provided herein including hearing aids and refractive keratoplasty
Corrective appliances artificial aids devices or equipment not specified herein including penile implants
Homemaker services
Long term rehabilitative therapy
Eyeglasses and their fittings and contact lenses
Routine foot care
Charges for missed appointments phone calls completion of insurance forms copy or transfer of medical records returned checks or stop payment on checks
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Hospital Extended Care Benefits
What is covered The Plan provides a comprehensive range of benefits with no dollar or day limit when you are hospitalized under the care of a Plan doctor You pay a 100 copay per inpatient admission
Hospital care All medically 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 Specialized care units such as intensive care or cardiac care units
Extended care The Plan provides a comprehensive range of benefits up to 100 days per illness or condition when full time skilled nursing care is necessary and confinement in a skilled nursing facility is
medically appropriate as determined by a Plan doctor and approved by the Plan You pay nothing All necessary services are covered including
Bed board and general nursing care Drugs biologicals supplies and equipment ordinarily provided or arranged by the skilled
nursing facility when prescribed by a Plan doctor
Hospice care Hospice care as authorized by the Plan will be covered for members diagnosed with a terminal illness with a life expectancy of six months or less Covered services include the following
skilled nursing care home infusion therapy drugs for palliative care and pain management
services of a medical social worker services of a home health aide or homemaker
physical speech or occupational therapy durable medical equipment
routine medical supplies routine lab services
counseling including nutritional counseling with respect the Member's care and death bereavement counseling for immediate family members both before and after the
member's death and short term inpatient care including both respite care and procedures necessary for pain
control and acute chronic symptom management Respite care means non acute inpatient care for the Member in order to provide the Member's primary caregiver a temporary
break from caregiving responsibilities Respite care may be provided only on an intermittent non routine and occasional basis and may not be provided for more than five
days every 90 days
Ambulance service Benefits are provided for ambulance transportation ordered or authorized by a Plan doctor
Limited Benefits Hospitalization for medical treatment of substance abuse is limited to emergency care Acute inpatient diagnosis treatment of medical conditions and medical management of withdrawal symptoms
detoxification acute detoxification if the Plan doctor determines that outpatient management is not medically appropriate See page 19 for nonmedical Substance Abuse Benefits
What is not covered Personal comfort items such as telephone and television Custodial care rest cures domiciliary or convalescent care
Inpatient dental procedures
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Emergency Benefits
What is a medical Emergency means the sudden onset of a medical condition that manifests itself by symptoms emergency of sufficient severity including severe pain that the absence of immediate medical attention
could reasonably be expected by a prudent lay person who possesses an average knowledge of health and medicine to result in i serious jeopardy to the mental or physical health of the
individual or ii danger of serious impairment of the individual's body functions or iii serious dysfunction of any of the individual's bodily organs or iv in the case of a pregnant
woman serious jeopardy to the health of the fetus
Emergencies within If you are in an emergency situation please call your primary care doctor or a nurse advisor at the service area 1 800 382 9625 In extreme emergencies if you are unable to contact your doctor or a nurse
advisor contact the local emergency system e g the 911 telephone system or go to the nearest appropriate medical facility
If you need to be hospitalized you or your representative must notify your primary care doctor within 48 hours or on the first working day following your admission unless it was not
reasonably possible to do so 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 A 50 copay per hospital emergency room visit or a 20 copay 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 of 100 and the emergency room visit copay is waived
Emergencies Benefits are available for any medically necessary health service that is immediately outside required because of injury or unforeseen illness If an emergency occurs when you are
the service area temporarily outside the service area you should obtain care at the nearest medical facility You or your representative is responsible for notifying your primary care doctor within 48
hours or on the next business day
If you need to be hospitalized you or your representative must notify your primary care doctor within 48 hours or on the first working day following your admission unless it was
not reasonably possible to do so 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
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Plan pays Reasonable charges for emergency care services to the extent the services would have been covered if received from Plan providers
You pay A 50 copay per hospital emergency room visit or a 20 copay 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 of 100 and the emergency room visit 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 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 Charges incurred after your condition would permit you to travel to the nearest Plan
facility
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 9
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 20 outpatient visits to Plan doctors consultants or other psychiatric personnel each calendar year you pay a 20 copay for each covered visit all charges thereafter
Inpatient care Up to 30 days of hospitalization each calendar year you pay a 100 copay per admission for the first 30 days all charges thereafter
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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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
Treatment for mental retardation mental deficiency and learning disabilities Treatment which is not authorized by the Plan doctor
Substance Abuse
What is covered This Plan provides medical and hospital services such as acute detoxification services for the medical non psychiatric aspects of substance abuse including alcoholism and drug addiction
the same as for any other illness or condition and to the extent shown below the services necessary for diagnosis and treatment
Outpatient care Up to 20 outpatient visits for Plan providers for treatment each calendar year you pay a 20 copay for each covered visit all changes thereafter
The substance abuse benefit may be combined with the outpatient mental conditions benefit shown above provided such treatment is necessary and is approved by the Plan to permit an
additional 20 outpatient visits per calendar year with the applicable mental conditions benefit copayments
Inpatient care Up to 30 days per calendar year in a substance abuse rehabilitation intermediate care program in an alcohol detoxification or rehabilitation center approved by the Plan you pay a 100 per
inpatient admission copay subject to a lifetime maximum of 90 days all charges thereafter
What is not covered Treatment that is not authorized by the Plan provider
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 31 day supply or a quantity of 100 whichever is less You pay a 5
copay first tier a 10 copay second tier or a 25 copay third tier
All covered brand name and generic drugs are categorized into three specific tiers and each tier is assigned a copayment level
First tier Low cost prescription drugs typically generic drugs Second tier Moderate cost prescription drugs typically multi source brand name drugs A
multi source brand name drug is a brand name drug with a generic equivalent Third tier High cost prescription drugs typically single source brand name drugs A single
source brand name drug is a brand name drug without a generic equivalent
You may request a brand name drug and pay the difference between the brand name drug and the generic drug in addition to your appropriate copayment
Drugs are prescribed by Plan doctors and dispensed in accordance with the Plan's drug formulary Nonformulary drugs will be covered when prescribed by a Plan doctor The Plan
receives financial credits from drug manufacturers based on the total volume of claims processed for their products used by members These credits are used to help stabilize
premiums Reimbursements to pharmacies are not affected by these credits
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Covered medications and accessories include Drugs for which a prescription is required by law
Oral and injectable contraceptive drugs contraceptive diaphragms intrauterine devices and Norplant are covered under prescription drug or medical and surgical benefits
For members with diabetes insulin with a copay charge applied to each vial insulin syringes needles blood glucose test strips lancets and glucometers coverage for
glucometers is limited to one per member every 12 months Disposable needles and syringes needed to inject covered prescribed medication
Intravenous fluids and medication for home use and some injectable drugs are covered under Medical and Surgical Benefits
Limited Benefits Drugs to treat sexual dysfunction are subject to dosage limitations Contact the Plan for the dosage limitations
What is not Drugs available without a prescription or for which there is a nonprescription equivalent covered 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 Diabetic supplies except needles syringes blood glucose test strips glucometers and
lancets as specifically covered including glucose test tablets and test tape Benedict's solution or equivalent and acetone test tablets
Drugs for weight control Drugs for cosmetic purposes
Drugs to enhance athletic performance Drugs to aid in smoking cessation including nicotine patches
Fertility drugs
Other Benefits
Dental care
Accidental injury Restorative services and supplies necessary to promptly repair but not replace sound natural benefits teeth The need for these services must result from an accidental injury you pay a 20 copay per
specialist doctor visit A treatment plan must be submitted within 60 days of the accidental injury and approved by the Plan
What is not covered Accidental injury to teeth caused by biting or chewing related injuries Other dental services not shown as covered
Vision care
What is covered In addition to the medical and surgical benefits provided for the diagnosis and treatment of diseases of the eye members may receive one eye examination every contract year including
lens prescriptions from designated Plan providers You pay a 10 copay per visit You pay an additional 25 copay for a contact lens examination from designated Plan providers
What is not covered Corrective lenses or frames Eye exercises
CARE MUST BE RECEIVED FROM OR ARRANGED BY PLAN DOCTORS
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Non FEHB Benefits Available to Plan Members
The benefits described on this page are neither offered nor guaranteed under the contract with the FEHB Program but are made available to all enrollees and family members who are members of this Plan The cost of the benefits described on
this page is not included in the FEHB premium and any charges for these services do not count toward any FEHB deductibles or out of pocket maximums These benefits are not subject to the FEHB disputed claims procedure
Trigon Individual Dental For an additional premium Trigon offers an individual dental program within its service area that covers both preventive and diagnostic services and
provides certain benefits for important restorative orthodontic and prosthodontic services Please call 1 888 7TRIGON for more information
Expanded Vision Care Trigon HealthKeepers offers a 25 discount on vision services and supplies when received from the Plan's vision care vendor This program is available at
no additional cost to you
Trigon HealthKeepers The Plan offers the Trigon HealthKeepers Family Health Program which Family Health Program
includes discounts at health clubs throughout Virginia and other health programs such as the award winning Baby Benefits prenatal care program the
24 hour Nurse Advisor Line the HealthLine Audiotape Library the Trigon HealthNews Newsletter and more The Trigon HealthKeepers Family Health
Program is available at no additional cost to you
Baby Benefits Program Trigon HealthKeepers offers Baby Benefits a prenatal program for expectant parents designed to promote a healthy pregnancy This program has been
recognized for its success by winning the C Everett Koop National Health Award HealthKeepers enrollees will be automatically enrolled when their
primary care doctor confirms pregnancy and will receive information materials access to a Baby Benefits nurse consultant a prenatal book and
gifts for the parents and baby This program is available to the enrollee at no additional cost
Benefits on this page are not part of the FEHB contract
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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 drug 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
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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 beyond our Under certain extraordinary circumstances we may have to delay your services or be control unable to provide them In that case we will make all reasonable efforts to provide you
with necessary care
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 We do not cover services and supplies that a local State or Federal Government agency Government Agencies directly or indirectly pays for
Section 8 FEHB FACTS
You have a right to OPM requires that all FEHB plans comply with the Patients Bill of Rights information about which gives you the right to information about your health plan its networks
your HMO 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
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If you want specific information about us call 1 800 421 1880 or in the Richmond area at 358 7390 or write to
HealthKeepers Inc P O Box 26623
Richmond Virginia 23285 0031
Where do I get Your employing or retirement office can answer your questions and give you a Guide information about to Federal Employees Health Benefits Plans brochures for other plans and other
enrolling in the materials you need to make an informed decision about FEHB Program When you may change your enrollment
How you can cover your family members What happens when you transfer to another Federal agency go on leave without
pay enter military service or retire When your enrollment ends and
The next Open Season for enrollment
We don't determine who is eligible for coverage and in most cases cannot change your enrollment status without information from your employing or retirement office
The benefits in this brochure are effective on January 1 If you are new to this plan your When are my benefits coverage and premiums begin on the first day of your first pay period that starts on or
and premiums effective 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 my family and and your unmarried dependent childrin under age 22 including andy foster or
me sepchildren your employing office of retirement office authorizes coverage for Under certain circumstances you mayt also get coverage for a disabled child 22 years of age or
older who is incapable of self support which is also authorized by your employing or retirement office
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 No new enrollment form is necessary
If you or one of your family members is enrolled in one FEHB plan that person may not be enrolled in another FEHB plan
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Are my medical and claims We will keep your medical and claims information confidential Only the following will records confidential have access to it
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 cards 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 Your old plan's deductible continues until our coverage begins a 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 my You will receive an additional 31 days of coverage for no additional premium when enrollment in this Plan Your enrollment ends unless you cancel your enrollment or
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 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
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Key points about TCC You can pick a new plan If you leave Federal service you can receive TCC for up to 18 months after you
separate If you no longer qualify as a family member you can receive TCC for up to 36
months Your TCC enrollment starts after regular coverage ends
If you or your employing office delay processing your request you still have to pay premiums from the 32 nd day after your regular coverage ends even if several months
have passed You pay the total premium and generally a 2 percent administrative charge The
government does not share your costs You receive another 31 day extension of coverage when your TCC enrollment ends
unless you cancel your TCC or stop paying the premium You are not eligible for TCC if you can receive regular FEHB Program benefits
How do I enroll in TCC If you leave Federal service your employing office will notify you of your right to 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
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
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How can I get a Certificate If you leave the FEHB Program we will give you a Certificate of Group Health Plan of Group Health Plan Coverage that indicates how long you have been enrolled with us You can use this
Coverage certificate when getting health insurance or other health care coverage You must arrange for the other coverage within 63 days of leaving this Plan Your new plan must reduce or
eliminate waiting periods limitations or exclusions for health related conditions based on the information in the certificate
If you have been enrolled with us for less than 12 months but were previously enrolled in other FEHB plans you may request a certificate from them as well
Inspector General Advisory Stop Health Care Fraud
Fraud increases the cost of health care for everyone If you suspect that a physician pharmacy or hospital has charged you for services you did not receive billed you twice for the same service or misrepresented any information do the
following Call the provider and ask for an explanation There may be an error
If the provider does not resolve the matter call us at 1 800 421 1880 or in the Richmond area at 358 7390 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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Summary of Benefits for Trigon HealthKeepers 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 Hospital Comprehensive range of medical and surgical services without dollar or day limit Care 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 16
Extended Care All necessary services up to 100 days per illness or condition You pay nothing .16
Hospice Care All necessary services You pay nothing 16
Mental Diagnosis and treatment of acute psychiatric conditions for up to 30 days of Conditions inpatient care per year You pay a 100 copay per admission for the first 30 days
all charges thereafter 18
Substance Up to 30 days in a substance abuse treatment center per year limited to a lifetime Abuse maximum of 90 days You pay a 100 per admission copay 19
Outpatient Comprehensive range of services such as diagnosis and treatment of illness or Care 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 primary care doctor office
visit 20 copay for an authorized specialty doctor office visit or a doctor house call For Ambula tory Outpatient Surgery you pay a 20 copay for services
received in a specialist's office and a 50 copay for services received in a freestanding or hospital based center 11
Home Health Care All necessary visits by nurses and health aides You pay nothing 13
Chiropractic Care Up to 20 outpatient visits per year You pay a 10 copay per visit 14
Mental Conditions Up to 20 outpatient visits per year You pay a 20 copay per visit 18
Substance Abuse Up to 20 outpatient visits per year You pay a 20 copay per visit 19
Emergency Reasonable charges for services and supplies required because of a medical Care emergency You pay a 50 copay per emergency room visit or a 20 copay
per visit to an urgent care center and any charges for services not covered by this Plan 17
Prescription Drugs prescribed by a Plan doctor and obtained at a Plan pharmacy You pay Drugs a 5 copay first tier 10 copay second tier or 25 copay third tier per
prescription unit or refill 19
Dental Care Accidental injury benefit You pay a 20 copay per doctor visit 20
Vision Care One eye refraction per year You pay a 10 copay per visit and an additional 25 copay for contact lens exams 20
Out of pocket Copayments are required for a few benefits however after your out of pocket Maximum expenses reach a maximum of 1,500 per member or 3,000 per family per
calendar year benefits will be provided at 100 This copay maximum does not include prescription drugs dental services vision care chiropractic services
or outpatient mental health and substance abuse care 7
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2000 Rate Information for
Trigon HealthKeepers
Non Postal rates apply to most non Postal enrollees If you are in a special enrollment category refer to the FEHB Guide for that category or contact the agency that maintains your health
benefits enrollment
Postal rates apply to most career U S Postal Service employees In 2000 two categories of contribution rates referred to as Category A rates and Category B rates will apply for certain
career employees If you are a career postal employee but not a member of a special postal employment class refer to the category definitions in The Guide to Federal Employees Health
Benefits Plans for United States Postal Service Employees RI 70 2 to determine which rate applies to you
Postal rates do not apply to non career postal employees postal retirees certain special postal employment classes or associate members of any postal employee organization Such persons not
subject to postal rates must refer to the applicable Guide to Federal Employees Health Benefits Plans
Non Postal Premium Postal Premium A Postal Premium B
Biweekly Monthly Biweekly Biweekly
Type of Code Gov't Your Gov't Your USPS Your USPS Your Enrollment Share Share Share Share Share Share Share Share
Self Only X81 66.14 22.05 143.31 47.77 78.27 9.92 78.27 9.92
Self and X82 167.97 55.99 363.94 121.31 198.76 25.20 198.76 25.20 Family
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